Provider Manual - Detroit Wayne Mental Health Authority
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Detroit-Wayne County Community Mental Health Agency Provider Manual For Operations and Procedures March 2012 1 Table of Contents Mission ......................................................................................... 8 Vision ........................................................................................... 8 Core Values ................................................................................ 9 Background .............................................................................. 11 Introduction .............................................................................. 12 Welcome…………………………………………………………………………….. 12 What is the D-WCCMHA Network .................................................................. 12 What is a Manager Comprehensive Provider Network (MCPN)? ............... 13 Governance .................................................................................................... 13 Contacting the Agency .................................................................................. 14 Observed Holidays.......................................................................................... 14 Enrollment ................................................................................ 16 Who is eligible for services? ........................................................................... 17 Adults with Severe Mental Illness ................................................................... 17 Children and Adolescents with Serious Emotional Disturbance ................. 17 Consumers with Development Disabilities .................................................... 18 Consumers with Substance-Related Disorders............................................. 18 Registering New Members ............................................................................. 19 Adult Benefit Waiver………………………………………………………………..19 Confirmation of Enrollment ............................................................................ 20 MCPN Transfers ................................................................................................ 20 Dis-enrollment ................................................................................................. 21 Coordination of Benefits ................................................................................. 21 Membership Card…………………………………………………………………..22 Covered Services..................................................................... 23 Enrollee Covered Services and Benefits............................................................ 24 Exclusions ............................................................................................. ……….26 Exclusions from the Agency and MCPNs Responsibility…………………..…27 Family Subsidy……………………………………………………………………..…27 Implementation of Core Values ....................... .......................29 Consumerism ................................................................................................... 30 Employment of Consumers Receiving Services ........................................... 32 Inclusion ........................................................................................................... 32 Recovery .......................................................................................................... 32 Peer Support………………………………………………………………………….33 Person Centered Planning Process and Approval ....................................... 33 2 Crisis Plan……………………………………………………………………………..34 Self Determination ........................................................................................... 34 Independent Facilitation……………………………...……………………..…….34 Compliance with Advance Directives ........................................................ ..35 Cultural Competence/Limited English Proficiency ................................... ,,,36 Meaningful Access/Accommodations......................................................... 37 Family-Driven and Youth Guided Principles……………………………………38 Essential Elements for Family Driven and Youth Guided Care……………...39 Adult Jail Diversion…………………………………………………………………..39 Housing Practice……………………………………………………………………..40 MCPN, CA and DCP Management of Services .................... 41 MCPN, CA and Direct Contract Provider (DCP) Management of Services.......................................................................... 42 Access Standards............................................................................................ 42 Customer Service ............................................................................................ 43 Emergency After-Hours Crisis Service ........................................................... 44 Equitable Residential Placement ................................................................... 44 Utilization Management Services and Supports .......................................... 44 Pre-Admission review and Prior Authorizations ........................................... 45 Denial of Authorizations ................................................................................. 46 Pre-Admission Review and Utilization Management Staff…………………..46 Inter-Rater Reliability………………………………………………………………..47 Guiding Principles and Other UM and Delegated Functions……………….47 Annual Review of Utilization Management Plan………………………………47 Appeals ........................................................................................................... 48 Clinical Appeal Process ................................................................................. 48 Reconsideration Reviews and 1st Level Appeals ......................................... 49 Second Opinion............................................................................................... 49 Medicaid Fair Hearings................................................................................... 49 Medicaid Appeal Process .............................................................................. 49 Advance Notice .............................................................................................. 50 Adequate Notice ............................................................................................ 50 Expedited Hearings ......................................................................................... 50 Discharge Planning ......................................................................................... 51 Out-of-Network Services ................................................................................ 51 Intensive Care Management Program ........................................................ 51 Managing Co-Occurring Substance Use Disorders ..................................... 52 Managing Consumers with Co-Occurring SED or SMI and Developmental Disabilities ............................................................................. 52 Coordination with Other Human Service Organizations ............................. 52 Chart: D-WCCMHA Delegated Functions ..................................................... 58 Credentialing............................................................................ 60 D-WCCMHA Credentialing ............................................................................. 61 Individual Practitioner ..................................................................................... 62 3 Primary Source Verification ........................................................................... 62 Credentialing and Re-Credentialing Process………………………………….62 Delegated Credentialing................................................................................ 63 CVO Credentialing Responsibilities ............................................................... 63 Initial Credentialing Process........................................................................... 64 Temporary/Provisional Credentialing of Individual Practitioners ............... 64 Deemed Status ................................................................................................ 64 Re-Credentialing Individual Practitioners ..................................................... 65 Criminal Background Checks ........................................................................ 65 Reporting Improper Conduct ......................................................................... 65 D-WCCMHA Credentialing Committee ........................................................ 65 Required Training…………………………………………………..66 Network Management ............................................................ 68 Network Administration .................................................................................. 69 MCPN Subcontractors ..................................................................................... 69 MCPN Conflicts ................................................................................................ 70 MCPN and Other Publicly Funded Human Service Organizations ............. 71 Staffing Standards............................................................................................ 71 Directory ........................................................................................................... 71 Quality Management/Improvement Program ..................... 72 Element I: Quality Improvement Program .................................................... 73 Element II: Systematic Process of Quality Assessment and Improvement ........ 74 Element III: Accountability to the Governing Body ..................................... 75 Element IV: QIP Supervision............................................................................ 76 Element V: Provider Qualification and Selection ........................................ 76 Element VI: Enrollee Rights and Responsibilities........................................... 77 Element VII: Utilization Management ........................................................... 78 Dispute Resolution Grievance and Appeals System (DRGAS) ....................................................... 79 Local Appeals for Medicaid Beneficiaries.................................................... 81 Guidelines ........................................................................................................ 82 Local Appeals: Additional Requirements ..................................................... 83 Customer Service .................................................................... 85 Overview of Customer Service ..................................................................... 86 Customer Service Office................................................................................. 86 Role of Agency ................................................................................................ 87 Role of Contractor .......................................................................................... 87 Sanctions ......................................................................................................... 89 MDCH Customer Service Standards .............................................................. 89 4 Customer Service Staff Training ..................................................................... 91 Customer Service Compliance Monitoring .................................................. 91 Customer Service Performance Measurement ............................................ 93 Limited English Proficiency ............................................................................. 94 Intended Beneficiary New Enrollee Orientations ......................................... 96 Grievance Process .......................................................................................... 99 Informal Grievance Process……………………………………………………...100 Formal Grievance Process………………………………………………………..101 State Fair Hearing Process ....................................................................... ….102 Consumer Affairs ........................................................................................... 103 Supported Consumer Employment ............................................................. 104 Recipient Rights ...................................................................... 105 The ORR Mission Statement……………………………………………………….106 Overview of Recipient Rights ..................................................................... ..106 Contractor and Subcontractor Responsibilities………………………………106 Sanctions ........................................................................................................ 107 Monitoring ...................................................................................................... 108 Employee training………………………………………………………………….108 Communication ..................................................................... 110 Sharing Information with Consumers ........................................................... 111 Sharing Information with Subcontractors and Line Staff ............................ 111 Marketing Standards ..................................................................................... 111 Reporting Requirements ........................................................ 114 Information Systems............................................................... 116 Information Systems Overview..................................................................... 117 MH-WIN .......................................................................................................... 118 Encounters ..................................................................................................... 118 Assessment Data ........................................................................................... 118 Funding ........................................................................................................... 118 Membership Lookups.................................................................................... 118 Finances .................................................................................. 119 Funding Sources ............................................................................................ 120 Medicaid Spend-Down................................................................................. 120 Payment Schedule ........................................................................................ 120 Payment Cell Notification............................................................................. 120 Reconsideration ............................................................................................ 120 Capitation Reconciliation............................................................................. 120 Reporting ........................................................................................................ 121 Billing .............................................................................................................. 121 D-WCCMHA Benefit Plan Covered Services………………………………….122 5 Claim and Encounter Submission ........................................ 123 Information to Include on Claim/Encounter Form ..................................... 124 Web-Based Encounter Submission .............................................................. 124 Compliance............................................................................ 125 Overview ........................................................................................................ 126 Fraud and Abuse ........................................................................................... 126 Health Insurance Portability and Accountability Act (HIPAA) .................. 127 Agency Policies............................................................................................. 127 Health Care Compliance Resources .......................................................... 127 Contacts………………………………………………………..….128 DWCCMHA Access and Referral Services……………………………………..129 Substance Abuse Coordinating Agencies……………………………………..129 State Hospitals………………………………………………………………………..129 MCPN Contact List…………………………………………………………………...131 Juvenile Services Contact List……………………………………………………..133 Medicaid Health Plans………………………………………………………………135 Uninsured Health Providers………………………………………………………….136 Definitions........................................................................... ….137 References…………………………………………………………154 Appendix I DSM-IV Adult Services Mental Health Diagnostic Codes (290-319) .......................................................... 156 Appendix II DSM-IV Children’s Services Mental Health Diagnostic Codes (290-319) .......................................................... 160 Appendix III DSM-IV Developmental Disabilities Diagnostic Codes..................................................................................................... 164 Appendix IV Coordinating Entities .................................................................. 166 Appendix V Board of Directors ........................................................................ 168 Appendix VI Frequently Used Websites ........................................................ 171 Appendix VII Coordination of Benefits Glossary .......................................... 173 Appendix VIII Performance Standards .......................................................... 176 Appendix IX Benefit Plan Covered Services Grid……………………………..185 Appendix X DWCCMHA Training Grid……………………………………………219 6 Appendix XI: Forms .................................................................................... 233 Notice of Rights of Wayne County Residents Notice of Right for Wayne County Residents when Denied CMH Services ...................................................................................... 234 Request for Second Opinion.............................................................. 236 Notice of Hearing Rights Individual Plan of Service (IPOS) ............ 237 Advance Action Notice ..................................................................... 240 Adequate Action Notice ................................................................... 242 Local Appeal Request Form .............................................................. 243 Request for Hearing Instructions........................................................ 245 Request for Hearing ............................................................................ 246 Administrative Tribunal Request Form .............................................. 247 Directions for Local Appeal Log ........................................................ 248 Local Appeal Log ............................................................................... 249 Local Appeal Monitoring Tool ........................................................... 251 Local Appeal Acknowledgement Letter .......................................... 255 Local Appeal Notice of Disposition .................................................. 256 Local Appeal Disposition Form.......................................................... 257 Report of Critical Event / Sentinel Event Form.................................. 258 Psychotropic Medications Consent Form ........................................ 261 Provider Data Worksheet ................................................................... 262 Customer Service Forms ......................................................................... 266 MCPN New Enrollee Welcome Letter................................................ 267 Intended Beneficiary Feedback Form ............................................. 268 Intended Beneficiary Orientation Receipt Form .............................. 269 Customer Service Orientation Monthly Report ............................... 270 Customer Service MCPN Monthly Activity Report…………………...271 Customer Service Monitoring Tool Sample ..................................... 272 Customer Service Monitoring Site Review Tool................................ 273 Visit the Detroit-Wayne County CMH Agency website at www.waynecounty.com or www.dwccmha.com for updates, brochures, and other documents. 7 Detroit-Wayne County Community Mental Health Agency Mission Statement The Detroit Wayne County Community Mental Health Agency (D-WCCMHA) will strive to: Determine Needs, Plan, Fund, Implement, Coordinate, and Monitor a Full Range of Appropriate, Accessible, Qualitative, Efficient, Effective, Consumer Centered, Culturally Competent Mental Health Programs and Services; Provide Services in a Dignified and Respectful Manner in the Least Restrictive Environment Possible; and, Provide Services within the Resources Available and within Local, State, and Federal Requirements. Vision and Guiding Principles The Agency is a public entity committed to promoting, creating, and ensuring an accessible, culturally competent, clinically effective, resource efficient, healthcare system in support of health and safe communities, which holds the needs, dignity, and rights of Consumers to be paramount. The guiding principles of this vision are: Optimum healthcare accessibility for consumers will be based on the care population’s needs, resources, and the optimal service delivery system Management of information is essential to the achievement of our vision The Agency will provide the right service, at the right time, in the most effective consumer-sensitive environment, at the right cost We will strive to provide our most vulnerable populations with medically necessary services to ensure public health and safety. However, our stewardship is to maximize resources available for care We will be a “Center of Excellence” in the creation, dissemination, and evaluation of mental healthcare practices, standards, outcomes, and policies Given the immensity of need, and the scarcity of resources, we value collaboration over fragmentation and competition 8 Core Values The core values of the D-WCCMHA are: Consumerism Inclusion Recovery Relapse Prevention Person-Centered Planning Cultural Competence Meaningful Access Effective Freedom Family-Driven and Youth-Guided Principles Adult jail Diversion Housing Practice D-WCCMHA assures that these values are maintained through the following activities, oversight, and requirements: The quality and array of supports and services are to be provided in a like manner to all priority populations. The design and delivery of mental health supports and services will support consumer self-determination and independence. All supports and services will be provided in a manner that demonstrates cultural competency. Those with the greatest need (i.e., the Consumers with severe impairments and/or those most at risk) will be appropriately served as first priority. The rights of individuals will be preserved and protected. Consumers and families will have a meaningful and valued role in design, service delivery, and evaluation of services. Consumers will be empowered to guide their own supports and services planning and provided reasonable choices of supports and services. Efforts to maintain and further expand consumer-operated and controlled alternatives will be pursued. Partnerships will be continuously developed in the community with an intention of increasing the community’s desire and capacity accommodate people with disabilities and their families. to support and Prevention activities that serve to inform and educate Consumers will be carried out with the intent of reducing the risk of severe dysfunction. 9 Collaborative relationships, which may include shared funding arrangements with other community agencies with a shared population, will be promoted. Community-based rehabilitation, recovery and inclusion into community life will be promoted. Public funds will be expended in a manner that is legal, prudent, and ethical. Management of existing resources will continually improve by moving away from high cost, highly structured and regulated service models to more individualized, cost-effective services and supports for consumers, which may included options for consumer-directed or managed services and supports. Savings generated through increased efficiencies will be reinvested into systems, supports and services as determined by the Agency consistent with the policy directions of the MDCH. 10 Detroit-Wayne County CMH Agency Background The Detroit Wayne County Community Mental Health Agency (Agency) was created pursuant to Michigan Law and the Michigan Mental Health Code. The Agency has been in operation since October 1968 when the then Wayne County Board of Supervisors approved the joining of Wayne County (County) with the City of Detroit to create the Agency. The Agency is governed by a twelve (12) member Board of Directors, with six (6) directors appointed by the Mayor of the City of Detroit, and six (6) directors appointed by the Wayne County Chief Executive Officer. The Agency is a division of the County Department of Health and Human Services. The Executive Director is hired by the Board of Directors and is responsible for implementing all the functions of a community mental health services program as mandated in the Michigan Mental Health Code. The Agency is responsible for managing specialty services for Consumers with or at risk for serious emotional disturbance (SED), severe mental illness (SMI), developmental disabilities (DD), substance abuse, and MIChild beneficiaries. The Agency manages a full array of specialty mental and substance abuse services through contracts with Managers of Comprehensive Networks (MCPNs), two Substance Abuse Coordinating Agencies, and other contractors. Historically, the State of Michigan and the Agency financed and managed mental health and substance abuse services through individual contracts with providers. Services were reimbursed through fee-for-service, net cost or grant contracts. Federal and State mandates for greater accountability, improved access to care, and a need for a flexible and innovative service delivery system prompted the Michigan Department of Community Health (MDCH) to apply for a waiver. MDCH was granted the wavier October 1998. MDCH grandfathered all Community Mental Health Service Providers (CMHSP) from October 1998 through September 2002. Beginning October 1, 2001 all existing CMHSPs had to complete an Application for Participation (AFP) and satisfy the State that it met the standards for delivery of services as a Specialty Prepaid Health Plan. The Agency completed that process and on August 27, 2002, was selected to continue as the prepaid health plan for the Detroit-Wayne County area. 11 Introduction to Detroit-Wayne County CMH Agency (D-WCCMHA) Provider Manual Welcome Welcome to the D-WCCMHA Comprehensive Provider Network. As a contractor and D-WCCMHA partner, you will assist the Agency in meeting its mission of service to Consumers with or at risk for developing serious emotional disturbances, severe mental illness, development disabilities, substance abuse, and MIChild beneficiaries. This manual documents and clarifies contractual requirements for participants in the D-WCCMHA provider network. The manual is intended to assist the MCPNs, their subcontractors, coordinating agencies, and other D-WCCMHA contractors to perform day-to-day operational activities. In some instances, the manual may direct you to a specific policy or an additional document(s) that provides more detail. Updates and revisions will be disseminated as existing policies, procedures, and processes are revised or new ones are developed. All comments and feedback that will assist the Agency in making this manual more useful are appreciated. Comments should be submitted electronically. Federal and State law, the MDCH/CMHSP contract, and the Agency/MCPN contract govern the Agency network relationships and respective duties. To the extent that there is any apparent/perceived contradiction between this Manual and the governing authorities, the Agency shall resolve the issue and amend the manual as necessary What is the D-WCCMHA Network? The D-WCCMHA network is a comprehensive group of contracted organizations to provide services for the SMI, SED, and DD eligible populations in Wayne County. The network is comprised of: Managers of Comprehensive Provider Networks and their subcontracted providers Care Link Network (MI/SED) Community Living Services (DD) Consumer Link Network (DD) Gateway Community Services (MI/SED) Synergy Partners (DD) Substance Abuse Coordinating Agencies Bureau of Substance Abuse, Prevention, Treatment and Recovery Southeast Michigan Community Alliance (SEMCA) Other Agency Contractors 12 For example: Wayne County Juvenile Detention Facility Wayne County Jail Specified grant funded providers What is a Manager of Comprehensive Provider Network (MCPN)? The Michigan Department of Community Health, in their revised plan for procurement, required D-WCCMHA to develop a vertically integrated network of Provider of Specialty Service Networks (PSSN) to ensure choice for Consumers receiving publicly funded mental health services. The Managers of Comprehensive Provider Networks (MCPN) are the Agency PSSNs. An MCPN is a business contracting entity established to develop and manage a comprehensive network of providers who can meet the needs of individuals with or at risk of developing severe mental illness, serious emotional disturbance, developmental disabilities, substance abuse, and MIChild. The ultimate goal of the D-WCCMHA and each MCPN is to provide choice and access to quality care and services. MCPNs are: NOT managed care plans NOT insurance companies Governance As defined by the Michigan Mental Health Code, the MCPN governing body must include individuals in the system. At least one-third of the governing body must be primary or secondary consumers. At a minimum, 50% of the one-third member representatives must be primary consumers. MCPNs must provide consumer representatives with transportation to and from meetings of the governing body. The MCPN must publicize the availability of transportation so that primary consumer representatives can take advantage of the available transportation. The MCPN must have a policy and program Advisory Council comprised of consumers. The Advisory Council must meet on a monthly basis to review and provide input for existing, new and revised policies, procedures, and programs. Documentation of the Advisory Council meetings must include registration/signin of attendees, agenda and minutes of the meeting, and recording the directives of the Council. MCPNs must be able to demonstrate that they have promoted the existence of similar advisory councils within their provider networks. 13 Contacting the Agency Address 640 Temple, 8th Floor Detroit, MI 48201-2558 Phone 313-833-2500 Fax 313-833-2156 Customer Service 1-313-833-3232 1-888 490-9698-Toll Free TTY Line 1-800-630-1044-Toll Free Recipient Rights TDY Line 1-888-339-5595-Toll Free 1-888-339-5588-Toll Free 24 Hour Help Line TTY 1-800-241-4949-Toll Free 1-800-870-2599-Toll Free The Agency maintains office hours Monday through Friday - 8:00 AM to 5:00 PM. Observed Holidays The Agency is closed the following holidays: New Year’s Day Martin Luther King’s Birthday Memorial Day Independence Day Labor Day Columbus Day Thanksgiving Day Day following Thanksgiving December 24th through January 1st General Election Day 14 Enrollment 15 Enrollment The Detroit-Wayne County Community Mental Health Agency provides mental health and substance abuse services for Consumers with or at risk for serious emotional disturbance, severe mental illness, developmental disabilities, substance abuse, Adult Benefit Waiver and MIChild beneficiaries. Our programs are designed to give individuals, within the identified populations, greater choice and involvement in their treatment. The cornerstones of this program are: (1) providing choice, (2) PersonCenter Planning principals, and (3) maximizing the use of and developing new community based services. Services are provided through the Managers of Comprehensive Provider Networks, Substance Abuse Coordinating Agencies, and other Agency contractors. The enrollment process is centralized through the Agency’s Access Center. The Access Center provides screening and eligibility determinations for all applicants seeking community mental health services. However there are currently exemptions to the Centralized Access Center process, which are the following: Inpatient and crisis services, which includes hospitals and screening centers Outpatient providers managing crisis or emergent situations with an individual that walks into their facility Direct Contract Providers providing services through a direct contract with the Agency All Criminal Justice programs; which include the Michigan Prison Reentry Initiative; Early Release Program; Wayne County Jail; Juvenile Detention Facility; and the Juvenile Assessment Center Infant Mental Health Housing and Urban Development (HUD) Persons discharged from hospitals Children in Foster Care under the auspices of the Michigan Department of Human Services (DHS) Eligibility for Enrollment with D-WCCMHA Wayne County residents with or at risk for developing serious emotional disturbance, severe mental illness, developmental disabilities, and Consumers enrolled in the MIChild Program are eligible. The following criteria define Consumers with severe mental illness, serious emotional disturbance, and developmental disabilities. Substance abuse services are managed through Detroit Health Department Bureau of Substance Abuse (DHDBSA) and Southeast Michigan Coordination Agency (SEMCA). Based on the Michigan Mental Health Code, services are available to eligible Consumers regardless of the ability to pay. Therefore, neither the lack of funds nor the ability to directly pay through private funds or insurance can be a barrier to receiving services if the person is in the priority population. Wayne County residents who are in the priority population and have private insurance or are able to directly pay the cost of services are eligible for community mental health services. The following criteria define Consumers with severe mental illness, serious emotional disturbance, developmental disabilities, and substance abuse. 16 Adults with Severe Mental Illness Severe mental illness is a diagnosable mental, behavioral, or emotional disorder that exists or has existed within the past year for a period of time sufficient to meet diagnostic criteria listed in Appendix I and has resulted in functional impairment that substantially interferes with or limits major life activities. Degree of Disability is defined as substantial disability or functional impairment in three or more primary aspects of daily living such that self-sufficiency is markedly reduced. This includes: Personal hygiene and self care Activities of daily living Self-direction Learning and recreation, or Social transactions and interpersonal relationships. In older Consumers (55 or older), functional impairment may also include: Loss of mobility, Sensory impairment, Loss of physical stamina to perform activities of daily living, Loss of ability to communicate immediate needs as the result of medical conditions requiring professional supervision, and /or Conditions resulting from long-term institutionalization. Duration of Illness is defined as: Evidence of six continuous months of illness, symptomatology, or dysfunction, Six cumulative months of symptomatology or dysfunction in a 12-month period, and Expectation that the symptoms/dysfunctions will continue for more than six months. Prior Service Utilization is defined as: Four or more admissions to a community inpatient unit/facility in a calendar year, Community inpatient hospital stay exceeding 30 days in a calendar year, State inpatient hospitalization exceeding 60 days in a calendar year, and/or More than 20 community mental health visits (e.g., individual or group therapy) in a calendar year. Children and Adolescents with Serious Emotional Disturbance Serious emotional disturbance is a diagnosable mental, behavioral, or emotional disorder that exists or has existed during the past year for a period of time sufficient to meet diagnostic criteria specified in Appendix II and results in functional impairment that substantially interferes with or limits the minor’s role or functioning in family, school, or community activities. 17 Degree of Disability is defined as severe emotional/behavioral Impairment (not solely the result of mental retardation or other developmental disability, epilepsy, drug abuse, or alcoholism) that results in substantial functional limitation of two or more of the following major life activities: Self-care at an appropriate developmental level, Self-direction, including behavioral control, Capacity for living with family or family equivalent, Social functioning, Learning, and Receptive and expressive language. Duration of Disorder is defined as: Evidence of six continuous months of illness, symptomatology or dysfunction, Six cumulative months of symptomatology or dysfunction in a 12-month period, and Diagnosis (e.g., schizophrenia) such that condition is likely to continue for more than one year. Prior Service Utilization is defined as: Four or more admissions to a community inpatient unit/facility in a calendar year, Community inpatient hospital stay exceeding 45 days in a calendar year, State inpatient hospitalization exceeding 60 days in a calendar year, and/or More than 20 community mental health visits (e.g., individual or group therapy) in a calendar year. Consumers with Development Disabilities Developmental Disability is defined as: (1) An individual age birth to five years with substantial developmental delay or a specific congenital or acquired condition such that there is a high probability of resulting developmental disability as defined below if services are not provided. (2) An individual older than five years, with a severe, chronic condition that meets all the following criteria: Mental or physical impairment(s) or a combination of mental and physical impairment(s) that meeting the following criteria: Manifested before 22 years of age Continue indefinitely Substantial functional limitation in three or more of the following areas of major life activities: 18 Self care, Receptive and expressive language, Leaning, Mobility, Self-direction, Capacity for independent living, and/or Economic self-sufficiency. Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. Consumers with Substance-Related Disorders Consumers meeting the criteria for one of the Substance-Related Disorders found in the DSM IV are eligible for services. Clinical eligibility determination includes assessment, diagnosis, and application of the American Society for Addiction Medicine (ASAM) patient placement criteria for admission, continued stay, discharge/transfer, and referral for treatment. Consumers with Substance-Related disorders are covered through the substance abuse coordinating agencies (CA): Detroit Health Department/Bureau of Substance Abuse, Prevention, Treatment, and Recovery (DHD-BSA). Southeast Michigan Community Alliance (SEMCA). The Agency has delegated the reporting requirement to the CAs, as related to providing substance abuse services and treatment to Medicaid Beneficiaries. Adult Benefit Waiver This program provides basic health coverage to residents of the State of Michigan with countable incomes at or below 35% of the federal poverty level. Registering New Members for Enrollment Registering new members is a two-step process: Step 1 For Consumers that are not listed in MH-WIN or not assigned to an MCPN, but are seeking mental health services, the consumer/family/guardian must contact the Agency’s Access Center, Pioneer Behavioral Health at 1-866-690-8257 to initiate the screening and eligibility process. A face to face screening shall be provided based upon choice/individual need. The Access Center shall inquire as to the existence/desire to complete an Advance Directive. As part of its triage process, Pioneer determines if the Person is requesting and is appropriate for mental health services. Once appropriateness for mental health services is determined, the Person is offered options of intake locations. Pioneer will assign an MCPN, and then enter the potential member and the assigned MCPN into MH-WIN. 19 Step 2 The Access Center will schedule the first intake appointment with the consumer/family/guardian based upon their choice of provider locations and available appointments which have been entered in MH_WIN by providers. Nonemergent intake appointments shall be scheduled within fourteen (14) days; and persons discharged from hospitals shall receive an appointment within seven (7) days. Confirmation of Enrollment The Access Center will make a determination of eligibility immediately following the telephonic/face to face screening process. The Access Center will send a Welcome Packet within 24 hours of enrollment. The Welcome letter shall include the information specific to Advance Directives. MCPN Transfers Consumers may select a new MCPN at any time. Consumers requesting a change in MCPN must be referred to the Detroit Wayne County Community Mental Health Customer Service Representative at 1-888-490-9698 to initiate the transfer. Requests received on or before the 19th of the month will be effective the first day of the following month. Requests received after the 19th of the month will be effective the first day of the subsequent month. The Access Center is responsible for initiating MCPN changes in the MH-WIN system and forwarding a list of the changes daily to the Customer Service Office. The MCPN and the current provider are required to cooperate with and assist the member in a smooth transition (e.g. provide clinical information, transfer personal property, etc.) to the new MCPN and subcontractor. A copy of the clinical record must be provided seven (7) business days prior to the Person’s transfer. Medication(s) and other personal care items must accompany the person at the time of transfer if the person is in residential care. Personal property, (e.g., clothes, small appliances, radios, etc.) must either accompany the residential Person at the time of transfer or be delivered to the Person within two (2) business days of the transfer. The cost of transfer is the responsibility of the MCPNs. The MCPNs must coordinate with each other and their respective subcontractors to cover the cost of transfers. MCPNS are free to establish funding means or plans to support the transfer process. Disenrollment Consumers may leave or disenroll from the network for a variety of reasons including relocation out of Wayne County, death, prison sentence (Michigan Department of Corrections), or case closure due to inactivity, e.g., clinical improvement, completion of treatment plan, or declination of services by the Person. Any time a Person is no longer requiring or receiving services, the MCPN must notify the Agency within one business day. Notification should be directed to the Agency’s Customer Service Office at 313-833-3232. 20 Coordination of Benefits The Agency’s contractors are responsible for identifying and coordinating covered services, benefits and determine the individuals’ ability to pay. They are also responsible for identifying other potential first and third party liabilities for payment of service. The Agency’s contractors must have a method to ensure that payments from the Agency are payments of last resort and that the best use of community resources and supports are explored for each person receiving services. Consumers may have a variety of other benefit coverages such as: Medicaid Medicare MIChild Blue Cross Blue Shield Veterans Administration Auto insurance carriers HMOs Other commercial insurance If the MCPN or other Agency contractors do not obtain this information directly from the individual, then each entity must establish a process with its subcontractors to obtain the information. The MCPN or its subcontractor or other Agency contractor must: Verify the Person’s eligibility for other benefit coverage, Bill the other coverage as primary payer, Notify the MCPN of such coverage, Notify the Agency of such coverage, and Notify the Agency of changes in insurance or other coverage status. The MCPN must assist Consumers in applying for and maintaining their eligibility and enrollment with: Medicare Medicaid MIChild Children's Waiver Children's Special Health Care Services Program (CSHCSP) Habilitation Supports Waiver Family Subsidy Support Program Plus Care SSI/SSD Social Security FIA programs such as food stamps, home help, medical assistance, pensions or retirement benefits Veterans' benefits WIC HUD/MSHDA (including Section 8) or other benefits or assistance 21 Other programs that result from subsequent waivers Assistance includes: Securing the appropriate application forms, Ensuring accurate completion of the forms, Delivering completed forms to the appropriate parties for processing, Status inquiries on applications if there is a delay in processing, and Filing appeals when benefits have been denied. For example: Deliver bills to the local Michigan Department of Human Services (formerly FIA) worker and follow-up to ensure the bills are recorded appropriately and Medicaid cards are issued for Consumers on spend-down. Membership Card The MCPN must issue enrolled Consumers a membership card with the following important information: Name of the MCPN, MCPN's 24-hour, 7-day per week toll-free telephone number, Agency’s Customer Service telephone number, and Detroit-Wayne County Community Mental Health Agency identified on the card. Re-issuance of an Enrollee membership card is to be honored upon request at no cost to the enrollee. The front of the Membership Card looks like this: MCPN NAME Member Name: Member ID #: For information call 800 (MCPN No.) For information about coverage or to change your MCPN call: Detroit–Wayne County Community Mental Health Agency at 888-490-9698 The back of the Membership Card looks like this: Detroit – Wayne County Community Mental Health Agency Providers must determine if other coverage is applicable 22 Covered Services 23 Covered Services Enrollee Covered Services and Benefits Covered services are based on the, MDCH/CMHSP contract and the Michigan Medical Services Administration Community Mental Health Services Program Manual. From time to time, covered services may change based on Federal, State and/or County mandates and requirements. The following is a partial list of services that are available for Consumers with, SED, SMI and DD within the D-WCCMHA network. All services and supports must be medically necessary/clinically appropriate, individualized and based on Person-Centered Planning. For a detailed list, please refer to the Medicaid Policy Manual. Hospital-Based Services: Acute Community Inpatient Psychiatric Hospitalization State Hospital Services Extended Observation (23-Hour Hold) Partial Hospitalization Programs ECT, Inpatient and Outpatient Psychiatric Consults/Treatment on General Medical Units Residential Services: Supported/Supervised Independent Living Homes for the Aged Personal Care in Licensed Residential Settings Intensive Crisis Residential Services General Adult Foster Care Specialized Residential Services for Children and Adolescents in Child Caring Institutions Specialized Residential Services for Adults and Older Adults Special Needs Residential for Adults and Children with Developmental Disabilities Community Based Programs for Consumers with SED/SMI: Applied Behavioral Services Assertive Community Treatment (ACT) Assessments Psychological Testing Case Management Services Child Therapy Crisis Interventions Department of Human Services (DHS) General Fund Benefit Department of Human Services (DHS) Serious Emotional Disturbance (SED) Waiver Enhanced Health Services Family Individual/Group Therapy Infant Mental Health 24 Intensive Crisis Stabilization Services Medication Administration Medication Review Mental Health Home-Based Services Occupational Therapy Parent Management Training Oregon Model (PMTO) Parent Support Partners Physical Therapy Psychosocial Rehabilitation/Clubhouse Programs Speech, Hearing, and Language Services Treatment Planning Transportation Community Inclusion and Integration Services Community Living, Training, and Supports Skilled Building Assistance Family Support Services Family Skills Development Respite Care Housing Assistance Peer-Operated Support Services Prevention and Consultation Services Wrap Around Services for Children and Adolescents Trauma Focused Cognitive Behavioral Therapy (TFCBT) Community Based Programs for Consumers with DD: Applied Behavioral Services Crisis Stabilization and Response Assessment and Evaluation Support and Service Coordination Prevention and Consultation Services Community Living Supports Support Staff including Chore Services Assistive Technology Environmental Modifications Housing Assistance Skill-Building Assistance Family Support Services Respite Care Services Family Skills Development Enhanced Health Care Services Assistance for Challenging Behaviors DD Habilitation Supports Wavier Supports and Services Chore Services Community Living Supports Enhanced Dental Enhanced Medical Equipment and supplies Enhanced Pharmacy Environmental Modifications 25 Family Training Home Based Services Habilitation Education Services Out-of-Home, Non-vocational Habilitation Personal Emergency Response Systems Prevocational Services Private Duty Nursing Respite Care Supports Coordination Supported Employment Children’s Wavier Assessments Behavior Management Review Case Management Child Therapy Crisis Intervention Emergency Telephone Services Mental Health Clinic Emergency Family and Individual Therapy Health Services Medication Administration Medication Review Occupational Therapy Physical Therapy Professional Treatment Monitoring Periodic Review of Treatment Speech, Hearing, and Language Services Treatment Planning Day Programs with Transportation Mental Health Disaster (Direct Service and Other Service) Ancillary Services Non-emergency transportation Guardianship Court Ordered Evaluations Exclusions Covered services must be medically necessary and/or clinically appropriate. The following services are covered as part of the CMH program, but are excluded from the MCPN capitated payment. The Agency maintains separate contracts outside the MCPNs for the provision of these services. For a further description of these services see the section on Coordination with Other Human Service Organizations. MCPNs and other Agency contractors are expected to work collaboratively which includes accepting and initiating referrals, sharing clinical information to ensure coordination of care, providing case management services for Consumers in Wayne County Jail and Juvenile Detention Center, delivering and any other type of service necessary to practice good clinical care. 26 27 The following is a list of excluded services and the responsible organizations: Substance Abuse Services City of Detroit, Department of Health and Wellness Promotion Bureau of Substance Abuse, Prevention ,Treatment and Recovery BSAPTR Substance Abuse Services-Wayne County, non-Detroit, Southeast Michigan Community Alliance SEMCA Omnibus Reconciliation Act (OBRA), Neighborhood Services Organization NSO Michigan Department of Career Development Vocational Rehabilitation Services Housing Urban Development (HUD)/Path Grants HUD Wayne County Juvenile Detention Facility Third Judicial Circuit Court/Clinic for Child Study Wayne County Jail, including Jail Diversion Services Wayne County Probate Court Wayne County Senior Services Wayne County Prosecutor’s Diversion Program Some countywide programs, i.e., Native Americans, Arabs, Chaldean, Chinese, Latino Block and Other Grants Respite Services (SED) Early-On (SED) MIChild Children’s Waiver Vocational Services-Lockheed Direct Care Wage Increase Exclusions from the Agency and MCPNs Responsibility The following organizations are funded by the State of Michigan to provide nonspecialized mental health services. Individuals who are served by these systems may require specialized services offered by the CMH network and become eligible for CMH Services. Medicaid Qualified Health Plans (Comprehensive Health Benefits and Early Periodic Screening, Diagnosis, and Treatment) Wayne County Department of Community Justice Wayne County Juvenile Assessment Center (JAC) Care Management Organizations and their Subcontractors Local School Districts Department of Human Services (DHS) Children with Special Health Care Services (CSHSCS)- Formerly Crippled Children’s Program Family Subsidy Michigan’s Family Support Program was established with the passing of Public Act #249 of 1983, the Family Support Subsidy Act. The Program is designed to provide financial help for families who are caring for their children, 17 years of age and younger, with severe disabilities in the family home. Monthly stipends are equivalent to the monthly maximum supplemental security income payment available in Michigan for an adult 28 recipient living in the household of another. Increases are determined annually by legislative appropriation. D-WCCMHA's Customer Service’s Family Subsidy Office may be contacted at 313-8332493. Representatives are available to assist with the following: – – – – – – Application process, Coordinating the submission of the application to MDCH, Provide information on the appeals process, Assist with the notification process of informing the family of the Agency’s determination, and Prepare various regulatory reports to MDCH Respond to state audits of records. The following documents are required to determine eligibility: – – – – – Multipurpose form (MDCH form1181) – Application, Child’s birth certificate (copy), Child’s Social Security Card (Copy), The family’s most recently filed Michigan Income tax form (copy), and School memorandum stating the child’s educational diagnostic category or Individualized Education Team Report with same (faxed directly from the child’s school or school district). Child must have one of the following diagnoses: – – – Cognitive Impairment (Severe), Severe Multiple Impairments, or Autism (school must verify child’s special education programming), A child diagnosed with Autism must also be enrolled in one of the following education programs: – – – Classroom program for students with cognitive impairment (Special Education Rule 340.1738). Classroom program for students with severe multiple impairments (Special Education Rule 340.1748). Classroom for students with autism (Special Education Rule 340.1758a or Rule 340.1758b) 29 Implementation of Core Values 30 Implementation of Core Values Defined The core values of the Detroit-Wayne County CMH system are: Consumerism Employment Inclusion Recovery Person-Centered Planning Self Determination Independent Facilitation Compliance with Advance Directives Cultural Competence/Limited English Proficiency (LEP) Meaningful Access/Accommodations Family-Driven and Youth-Guided Principles Adult Jail Diversion Housing Practice Guideline Each MCPN, Sub-Contractors, and Direct Contract Providers must adopt all MDCH and Agency established Best Practice Guidelines. Consumerism Each MCPN must adopt the MDCH Consumerism Best Practice Guidelines. MCPNs must actively promote consumerism by giving Consumers, family members, and advocates decision-making roles in the service design, implementation, delivery, and evaluation process. Primary and secondary consumers must be involved in the design and selection of the provider network, operational policies and procedures, and all other major aspects of decision-making. Examples of decision-making roles are: identifying in-service education topics, developing consumer hiring practices, reviewing utilization management policies, critiquing promotional brochures, identifying network gaps, etc. Consumer input maybe obtained through board membership, advisory councils, focus groups, public forums, interviews, or any other means that provides members with opportunities for meaningful input. MCPNs must establish a person/stakeholder advisory body composed of Consumers, family members, and advocates. The advisory body is responsible for advising the Executive Director and Board of Directors on all aspects of implementing consumerism including: (1) choice, (2) consumer-run services, and (3) consumer involvement in the design, implementation, delivery and evaluation of the network and network operations. Given the critical need the MCPNs have, it is expected that this body meets no less than monthly. However, once the body is fully constituted and all functions are implemented, it may choose to meet less frequently, but no less often than quarterly. MCPNs must include representation of primary and secondary consumers on their Board of Directors. Refer to the Governance section for additional details. As part of their Quality Improvement Programs, MCPNs must design an ongoing process for assessing consumer satisfaction. MCPNs are expected to conduct satisfaction 31 surveys on an ongoing basis, analyze the resulting responses, and use the results for continuous improvement. Consumer satisfaction results must be aggregated annually and reported to the MCPNs Board of Directors, its Advisory Body, and the Agency. The MCPN is also free to develop other methods of assessing satisfaction, including direct input through focus groups, and to gather ideas and responses from Consumers regarding their experiences with services. MCPNs must establish a mechanism for active participation of consumers, family members, and advocates in the quality improvement process. This includes meaningful participation in the evaluation of mental health and substance abuse services. MCPNs must establish consumer recognition and awards for special achievements through employment, public service, sports, education and other areas of accomplishments. MCPNs should take every opportunity to recognize consumer’s contributions at board meetings, proactively seek media exposure for consumer-run services and activities, and create forums for consumers to receive public recognition for accomplishments. MCPNs must ensure that mental health services are implemented within the context of the Person-Centered Planning process in order to provide choice, control, independence, and integration. MCPN policies and procedures must: Assure “Person-First Language” is utilized in all publications, formal communications, and daily discussions. “Person-First Language” means that when individuals receiving mental health services are mentioned in the same phrase with their disorder, the person is always referred to first. For example: the appropriate reference would be adults with mental illness versus mentally ill adults; children with serious emotional disturbance versus seriously emotionally disturbed children. Establish a mechanism to provide Consumers, including advocates or guardians, the information and counsel needed to make informed treatment choices. Establish a means to help Consumers and families examine and weigh their treatment and support options, financial resources, housing options, education and employment options. This also includes assisting individuals in learning how to make their own decisions and take responsibility for themselves. Design mechanisms to help Consumers understand his or her social obligations and develop interactive social skills. Assure that Consumers are provided opportunities and choices that will enable them to reach their fullest potential. Employment of Consumers Receiving Services MCPNs must: Involve Consumers in the design, delivery, monitoring, and evaluation of covered services. 32 Use their best effort to ensure that at least 10% of the aggregate of the MCPN and its contracted Provider Network are Consumers who are in paid positions of at least ten (10) hours per week. Increase their commitment and that of their contracted Provider Network to employ Consumers including making provisions for recruitment, placement and development of pay scales, benefits and training. Establish programs specifically dedicated to Persons’ interests, staffed by Consumers and/or family members. Demonstrate improvements in performance in employment of Consumers Solicit and ensure Persons’ input and involvement in the MCPN's Provider Network, its community and population needs assessment, and service planning activities. Inclusion Each MCPN must adopt the MDCH Inclusion best practice guidelines. MCPNs must assure programs and services are designed to support the principle of normalization. This includes delivery of clinical services and supports that: Use community-established resources before developing new or using those that serve only mental health programs. Address the social, age appropriate, cultural, and ethnic aspects of services and outcomes of treatment. Help consumers gain social integration skills and become more self-reliant Assist Consumers in obtaining compensated employment. Assistance may include, but is not limited to, helping Consumers develop relationships with co-workers, using assistive technology to obtain or maintain employment, or providing transportation to and from employment. Identify community support that can foster or promote inclusion. Assist Consumers to obtain/maintain permanent, individual housing integrated in residential neighborhoods. Help families develop and utilize both informal and community networks of supports and resources. Provide children with treatment services, which preserve, support, and in some instances, create a permanent, stable family (for example, adoption). Recovery Services and programs provided to Consumers with mental illness and related disorders shall strive to accomplish the following goals: Provide information to the general public to reduce the stigma of mental illness. Create environments for all Consumers in which the process of "recovery" can occur. Provide basic information about mental health, recovery, and wellness to Consumers and the public. 33 Peer Support Peer support services are an evidence-based model of care which consists of utilizing qualified peer support specialist in assisting individuals with their recovery from mental illness and substance use disorders. Peer Support Specialist provides individuals with support, mentoring and assistance in achieving community inclusion, participation, independence, recovery and resiliency. Peer Support Specialists participate as a team member in the person centered planning process based upon consumer choice and preference. Functional responsibilities of a Peer Support Specialist may include the following: Provide vocational assistance and support for consumers seeking educational and or training opportunities, finding a job, achieving successful employment activities and developing self employment opportunities i.e. skill-building or supported employment. Provide education and support for consumers seeking to achieve independence by acquiring alternative housing. Supportive activities may include assistance with completion of application; transportation to visit potential housing options; education and training related to supportive housing based on the needs and preference of the consumer. Provide education to consumers which enhances knowledge of the recovery process i.e. Person Centered Planning, Advance Directives, crisis planning and community integration etc. Assist with promoting consumer health and wellness initiatives. Participates on Agency-wide committees. Peer supports are a Medicaid b(3) covered service in the Michigan Medicaid Specialty Health Plan Provider Manual. Person Centered Planning Process and Approval The MCPN and other Agency contractors shall ensure implementation of the Person/Family-Centered Planning process for all individuals except those receiving short-term outpatient services (12 sessions or less annually) or medication reviews. Each MCPN shall ensure implementation of the Agency’s standardized PCP documents: preplanning, psychosocial assessment for adults and children, and the individualized plan of services/person/youth/family centered plan. Covered Services must be provided in accordance with Person/Family-Centered Planning (PCP) practices. All Agency contractors must promote family support approaches for Consumers living with their natural family. Contractors must also assure that there are choices available to Consumers for Covered Services, including, but not limited to, choice of case managers and offer self-determination models for adults. The PCP process must include both verbal and nonverbal translation of services when needed. The MCPN and other Agency contractors must ensure that all Covered Services provided by the contractor or its subcontractors are in keeping with the Michigan Mental Health Code, Agency Policies, the MDCH, and current, clinical guidelines. The MCPN must provide PCP training to its subcontractors/providers, staff, 34 families/guardians, and other stakeholders. For additional information reference the Agency Person-Centered Planning policy and the Performance Standards section of the Manual. Services and supports provided to minors and their families must be: Delivered in a family-centered approach implementing comprehensive services that address the needs of the minor and his/her family, and Individualized and respectful of the minor and family’s choice of services and supports. Crisis Plan Consumers shall be offered the opportunity to develop a Crisis Plan. MCPN and Providers shall ensure documentation of acceptance or decline of this opportunity is in the case record. Self Determination MCPNs and other Agency contractors must offer Self Determination arrangements to Consumers and document that services have been offered. The MCPN and other Agency contractors must provide training on Self Determination to its subcontractors/providers, staff, families/guardians, and other stakeholders. For additional information reference the Agency Self Determination Policy. Independent Facilitation The MCPNs, Sub-contracted provider networks, and direct contractors must ensure consumers are provided access to the option of independent facilitation services. Advocacy organizations, such as the ARC’s, National Alliance for the Mentally Ill (NAMI), and peer specialist or consumers/individuals receiving services, may be included in the pool of individuals/ organizations to provide this service. MCPNs, sub-contractors, and direct contractors must ensure that Individuals providing independent facilitation services meet the following criteria: Free of any conflict of interest (i.e. not employed at the organization he/she is providing the service), Have had criminal background checks that demonstrate no history of criminal activity, Have received training in the Independent facilitation process, Are knowledgeable of the person-centered planning process, and Are skilled facilitators. The Agency recommends that independent facilitators be reimbursed sixty dollars ($60) per plan, per year, for independent facilitation services. All Agency contractors must ensure that consumers and family members are given the opportunity to evaluate independent facilitation services through consumer satisfaction surveys immediately following the person-centered planning meeting. Quality improvement measures should be initiated, as necessary, based upon the results of the feedback from the survey process. 35 Compliance with Advance Directives Each MCPN, Centralized Access Center sub-contractors, and direct contractors must ensure compliance with Federal and State regulations and contractual responsibilities to inform consumers and their families of the consumer’s right understand and to develop Advance Directives for Medical and Mental Health Treatment within the context of the PCP process. D-WCCMHA Access Center and Providers must inform consumers that the decision to complete an Advance Directive is completely voluntary and is not a condition of care. Staff training and education, based upon written policies and procedures, concerning Medical and Psychiatric Advance Directives shall occur at least annually and following any substantive changes in State Law as soon as possible, but no later than 90 days after the effective date of the change in State Law. ▪ Consumers must be educated on the Advance Directive process. ▪ Enrollee/Consumer must be offered the opportunity to complete an Advance Directive. ▪ Understand the purpose and meaning of an Advance Directive. Consumers who choose to develop an Advance Directive must be able to give informed consent. The determination of the consumer’s ability to provide informed consent shall include an assessment of their ability to: Understand the need for treatment, Understand the treatment options (including no treatment and the potential implications) for the illness/ condition, Consider the possible benefits and drawbacks (such as side effects from medication) from each treatment, and Make a reasonable choice among the treatments available. MCPNs, sub-contractors, and direct contractors must ensure completion of an examination by a physician and a mental health professional (who can be a physician, psychologist, registered nurse, or masters-level social worker) for determination of the consumer’s ability to provide informed consent. The consumer may choose the physician and mental health professional they wish to make this determination. Findings must be documented in the medical record. There is no required form for completion of an Advance Directive. The Agency has developed a pamphlet and handbook respectively entitled "Advanced Directives for Medical and Mental Health Care Choices" and "Advance Directives-Medical and Mental Healthcare Advance Directive Handbook and Forms." Advance Directives shall be included in the Welcome packet and during New Enrollee Orientation process. Copies are available through the Agency Access Center and the providers. These 36 documents can also be downloaded for printing and distribution on the DWCCMHA web site under "Publications." Advance Directives must be signed by two competent adults, who are not immediate family member(s), treating provider(s), patient advocate, employee(s) of a hospital or behavioral health program of the consumer. Advance Directives do not require notary signature. Particular issues that may arise as part of an Advance Directive include: Do Not Resuscitate: It is important to train all involved staff regarding “Do Not Resuscitate” (DNR) Orders. A DNR order can be a part of the Advance Directive. If there is no Advance Directive, an adult consumer may consent to a DNR order verbally or in writing, if two adult witnesses are present. When consent is given verbally, one of the witnesses must be a primary physician or a physician affiliated with the hospital where the consumer is receiving care. Durable Power of Attorney: Staff must also be aware of “Durable Power of Attorney (DPOA) for health care. A DOPA is a legal Advance Directive that names a person (Patient Advocate) to act on the signer’s behalf in enacting decisions about the signer’s medical care if the signer becomes unable to make medical decisions for him or herself. Consumers must be made aware of where to file complaints concerning Advance Directives. Complaints may be filed with the MDCH State Survey and Certification Agency. Consumers must be aware that he/she may change or cancel the Advance Directive and the decision to do so for medical care goes into effect immediately. However, the consumer can stipulate that advance directives regarding mental health can be cancelled with 30 days notification. Consumer’s awareness must also include the fact that a MCPN/MCPN contractor or Medicaid care professional can refuse to honor their wishes concerning a specific mental or medical treatment, location, or professional if: There is a mental health/medical emergency endangering the life of the consumer or the life of another person. The treatment requested is unavailable. There is a conflict between the Advance Directive and the provisions set forth in a petition or court-ordered treatment. Cultural Competence/Limited English Proficiency MCPNs must subcontract with and make referrals to providers from different ethnic groups so that each person requiring culturally appropriate services may receive services from a provider who shares his or her cultural background, values, and perspective. To effectively demonstrate the MCPNs’ commitment to cultural and linguistic service competency, MCPNs must have these components in place: Method of assessment that reflects community demographics, 37 Method to ensure organizational cultural competency is achieved and maintained (includes MCPNs and their sub-contractors), Plan to identify, remedy, and otherwise improve cultural competency, Policies, and procedures for ensuring cultural needs are comprehensive and available to all staff, and Training is provided to all staff that effectively instills cultural competency. MCPNs shall coordinate with specialty providers of ethnic services, including American Indian Services, Latino Family Services, Chinese American Drop-In Center, Arab American, and Chaldean Community and Social Services Council. Meaningful Access Accommodations Each MCPN, CA and direct contract provider and other Agency contractors must comply with all Americans with Disability Act (ADA) requirements including Title VI of the Civil Rights Act of 1964, and Title II and III of the Americans with Disability Act of 1990(PL 101-336). The contractors must establish and implement policies and procedures that include: Individuals with visual, mobility, or communication limitations/impairments shall be assured full participation and maximum benefit from services offered and involvement in governance functions Services, programs, board meetings, and other governance functions must be accessible to and usable by individuals with disabilities. This includes, but is not limited to: Provision of language assistance services. Accommodations for service animals Ensuring that elevators are available in multi-story buildings. Ensure that parking lots have sufficient designated parking for vehicles with handicap permits. Provision of alternate methods to facilitate communication. Communication aids and alternative communication methods, including a qualified sign language interpreter or augmentative communication specialist, must be provided for Consumers, family members, and others who are involved in the provision of services and treatment. Accommodation shall be made at expense of the MCPN or the other Agency contractor. Accommodations must afford accessibility to the building, work site, and any areas used by consumers to enable individuals to perform all essential program functions. Arrangements for the provision of accommodations shall not depend on a request by the consumer or others involved in treatment. Staff shall receive annual training on resources and technology available for individuals with visual, mobility, or communications limitations/impairments. Documentation of these training sessions must be made available to the Agency upon request. 38 Family-Driven and Youth-Guided Principles Family-driven and youth-guided principles should be measured at several different levels: the child and family level, the system level and the peer-to-peer level. These principles incorporate all levels, and will be detailed under section D: Essential Elements. Families and youth, providers and administrators share decision-making and responsibility for outcomes. Parents, caregivers and youth are given accurate, understandable, and complete information necessary to set goals and to make informed decisions and choices about the right services and supports for individual children and their family as a whole. All children, youth and families (parents) have a biological, adoptive, foster, or surrogate family voice advocating on their behalf. Families and family-run organizations engage in peer support activities to reduce isolation, gather and disseminate accurate information, and strengthen the family voice. Families and family-run organizations provide direction for decisions that impact funding for services, treatments, and supports and advocate for families and youth to have choices. Providers take the initiative to change policy and practice from providerdriven to family-driven and youth-guided. Administrators allocate staff, training, support and resources to make family-driven and youth-guided practice work at the point where services and supports are delivered to children, youth and families. Community attitude change efforts focus on removing barriers and discrimination created by stigma. Communities and public and private agencies embrace, value and celebrate the diverse cultures of their children, youth, and families and work to eliminate mental health disparities. Everyone who connects with children, youth, families continually advances their own cultural and linguistic responsiveness as the population served changes so that the needs of diverse populations are appropriately addressed. 39 Essential Elements for Family-Driven and Youth-Guided Care 1. “Family-driven” means that families have a primary decision-making role in the care of their own children as well as the policies and procedures governing care for all children in their community. This includes: Being given the necessary information to make informed decisions regarding the care of their children Choosing culturally and linguistically competent supports, services, and providers Setting goals Designing, implementing and evaluating programs Monitoring outcomes Partnering in funding decisions 2. “Youth-guided” means that young people have the right to be empowered, educated and given a decision-making role in their own care as well as the policies and procedures governing the care of all youth in the community, state and nation. A youth-guided approach views youth as experts and considers them equal partners in creating system change at the individual, state, and national level (SAMHSA). 3. “Family-run organization” means advocacy and support organizations that are led by family members with lived experience raising children with SED and/or DD thus creating a level of expertise. These organizations provide peer-to-peer support, education, advocacy, and information/referral services to reduce isolation for family members, gather and disseminate accurate information so families can partner with providers and make informed decisions, and strengthen the family voice at the child and family level, service delivery level and systems level. Adult Jail Diversion There is a general consensus with the principle that the needs of the community and society at large are better served if persons with serious mental illness, serious emotional disturbance or developmental disability who commit crimes are provided effective and humane treatment in the mental health system rather than be incarcerated by the criminal justice system. It is recognized that many people with serious mental illness have a co-occurring substance disorder. This practice guideline reflects a commitment to this principle and conveys Michigan Department of Community Health (MDCH) jail diversion policy and resources for Community Mental Health Services Programs (CMHSPs). The guideline is provided as required under the authority of the Michigan Mental Health Code, PA 258 of 1974, Sec. 330.1207-Diversion from jail incarceration (Add. 1995, Act 290, Effective March 28, 1996). Section 207 of the Code states: “ Each community mental health service program shall provide services designed to divert persons with serious mental illness, serious emotional 40 disturbance, or developmental disability from possible jail incarceration when appropriate. These services shall be consistent with policy established by the department.” The guideline outlines CMHSP responsibilities for providing jail diversion programs to prevent incarceration of individuals with serious mental illness or developmental disability who come in contact with the criminal justice system. A separate practice guideline will address Juvenile Diversion of children with serious emotional disturbance. Jail diversion programs are intended for individuals alleged to have committed misdemeanors or certain, usually non-violent, felonies and who voluntarily agree to participate in the diversion program. Housing Practice Guideline The Michigan Department of Community Health recognizes housing to be a basic need and affirms the right of all consumers of public mental health services to pursue housing options of their choice. Just as consumers living in licensed dependent settings may require many different types of services and supports, persons living in their own homes or sharing their household with another may have similar service needs. Responsible Mental Health Agency’s (RMHA) shall foster the provision of services and supports independent of where the consumer resides. When requested, PMHAs shall educate consumers about housing options and supports available, and assist consumers in locating habitable, safe, and affordable housing. The process of locating suitable housing shall be directed by the consumer’s interests, involvement and informed choice, Independent housing arrangements in which the cost of housing is subsidized by the RMHA are to be secured with a lease or deed in the consumer’s name This policy is not intended to subvert or prohibit occupancy in the participation with community based treatment settings such as an adult foster care home when needed by an individual recipient. 41 MCPN, CA and DCP Management of Services 42 MCPN, CA, and Direct-Contracted Provider (DCP) Management of Services The Agency has delegated the management of the comprehensive service array for Consumers to the Access Center, MCPNs, CAs and DCPs. The MCPNs, CAs, and DCPs have the responsibility to ensure that services are accessible, are appropriate to meet the consumers needs, and are provided in the least restrictive environment. Each MCPN must submit a current list of its subcontractors to the Agency on a monthly basis. That list must include at a minimum: Complete contact information: Sub-contractor’s name Address Telephone number Contact person NPI number Type of service A column indicating that the provider is/is not accepting referrals Any delegated services or responsibilities including: Utilization management 1. Level of care assessment and service/support selection 2. Service authorization 3. Utilization Review Customer services 1. Information services 2. Complaint, Grievance, Appeals processes 3. Community Benefit Provider network management 1. Network development 2. Network policy development 3. Credentialing and Privileging Quality management 1. Standards setting 2. Performance measurement 3. Regulatory management or Corporate compliance 4. Managing Review processes 5. Provider education and training Financial management 1. Financial operations and risk management 2. Claims management Information systems management Access Standards 43 The following are the access standards that must be adopted and demonstrated in the Quality Management Program: 30 Minutes or 30 Miles: Consumers must have reasonable access to all types of covered services. Consumers receiving services must not be required to travel greater than 30 minutes or 30 miles to receive services. Emergent: Must be seen immediately by a provider for a face-to-face evaluation by a mental health professional. Urgent: Must be seen by a mental health professional for a face-to-face evaluation within 24 hours of the request for services (including transfer between levels of care during a chemical dependency episode). Routine: Must be seen by a mental health professional for a face-to-face intake/evaluation within 14 calendar days of the request for service. Ongoing Services: Must be established within 14 calendar days from the intake/evaluation. Acute Inpatient: Assessment, determination, and disposition must be made following medical clearance and within 3 hours of the request. Discharge from Hospital: A psychiatrist must see Consumers within seven (7) calendar days of discharge from a state, community, or partial hospital program. Customer Service The Access Center and MCPNs must establish and maintain a customer service function, including toll-free telephone service for the hearing impaired and ensure availability of a TTYDD phone system during normal business hours to: Receive telephone calls and meet personally with Consumers requesting and receiving services. Respond to questions. Resolve complaints informally (local dispute resolution) through direct discussion with the parties involved. (For example: a complaint of inability to obtain an appointment with a psychiatrist should result in the MCPN staff immediately contacting the selected network provider and securing an appointment for the Person. This process includes communicating the resolution to the Person and following up to ensure that the agreed on resolution to the complaint was implemented to the satisfaction of the Person. Manage and refer local dispute resolution, grievances, and recipient rights complaints to the appropriate party for further action as necessary. Track and trend information from informal complaints for monitoring and improving the performance of its providers. For additional information about Customer Service, please see the Customer Service section of this manual. 44 Emergency After-Hours Crisis Services The MCPN must provide after-hours telephone and face-to-face coverage for its Consumers. After-hours coverage includes the availability of locations throughout the County where Consumers can obtain screening for hospitalization 24/7, intensive crisis stabilization including mobile crisis outreach for face-to-face after-hours services by nurses, physicians, social workers, and psychologists. Additionally, the MCPN must provide after-hours telephonic coverage for Consumers in care by knowledgeable mental health professionals familiar with the Consumer’s care. It is expected that the MCPN holds its subcontractors responsible and accountable for crisis intervention including after-hours prescription coverage and arrangement for next day’s appointment. The DCPs must provide information to Consumers at intake regarding how to access emergency after-hours crisis services and access to 911 emergency services line. The MCPN must provide the emergency access and after-hours contract procedures to Pioneer Behavioral Health and the Agency. Additionally, the Agency maintains a contract with Pioneer Behavioral Health for emergency telephone services and crisis intervention for the general public. Equitable Residential Placement MCPNs must ensure that residential placement is provided to eligible Consumers fairly and equitably. MCPNs cannot establish waiting lists that disadvantage or prevent eligible Consumers from timely residential placement. MCPNs must establish policies and procedures to guide residential placement decisions. The Agency recognizes there are varying levels of care provided in the residential environment. In those instances where the needs of two or more individuals can similarly be met in a residence, the individual first requesting placement must have priority. MCPNs and subcontractors must track the date of request for placement along with the requesting individual’s name and the name of the person to be placed in the residence Utilization Management Services and Supports The Detroit Wayne County Community Mental Health Agency (Agency) is under contract with the Michigan Department of Community Mental Health (MDCH) as a Prepaid Inpatient Health Plan (PIHP) and Community Mental Health Service Program (CMHSP). The Agency is required to have a written Utilization Management Program that describes all core utilization management functions including delegated functions. The Agency delegates certain Utilization Management activities to the Access Center, the MCPNs and the Direct Contractors and requires each of them to have a comprehensive written Utilization Management Plan that integrates the Agency’s Utilization Management Program Description. The Agency has developed and implemented Standard Operating Procedures, Clinical Protocols, Evidence Based and Promising Practices and standard reporting formats for use by the Access Center, the MCPNs and/or Direct Contractors. 45 Some of the core activities of the Access Center, the MCPNs and/or Direct Contractors include the following: Access and Eligibility Determination utilizing CALOCUS/LOCUS and/or DD Screening tool Level of Care Assessment /Service Support Selection Authorization of Services, including prior and concurrent authorization and retrospective review First Level of Appeal for Services requiring Prior Authorization Conducting Inter-Rater Reliability for Pre Admission Reviews Monitoring of Service Providers’ Utilization Management Plans UM functions, including case reviews Preadmission Review and Prior Authorization The MCPNs are responsible for authorization of care and first level appeals for services requiring prior authorization. In order to authorize services, preadmission review is conducted. Pre-admission Review (PAR) is a systematic assessment of clinical information about an individual referred or recommended for services and should be based on meeting the needs of the eligible person. It must include a review of severity of illness and intensity of service criteria. Prior authorization is conducted telephonically by the MCPNs. The source of information for the UR activity comes from the requesting facility or provider. The request for authorization may come from the psychiatrist, physician, treatment team member or other utilization management staff member. It is expected that the caller is familiar with each case as a result of a face-to-face meeting with the consumer or as a result of an informed review of the clinical/medical record. MCPNs and Providers shall ensure submission of the standardized Preadmission Review findings into MH_WIN. Prior authorization is required for the following levels of care: Inpatient Psychiatric Hospital (MDCH Requirement): Each MCPN is responsible for screening requests for acute inpatient services 365 days a year (24x7x365). These emergency face to face evaluations may be available in a fixed site location and/or on a mobile basis as warranted based on need/volume in community. Continuous Coverage and Service Requirements: Each MCPN must have continual capacity 365 days a year (24x7x365) to perform needed continued stay review and appeals for inpatient psychiatric hospital services. Authorization by an Agency approved Pre-Admission Reviewer must be based on MDCH Level of Care Criteria. Each MCPN is responsible for notifying the Agency of their 24 hour access numbers for prior authorization and any changes in access to the services or procedures for requesting prior authorization. State facility services: These services are subject to prior authorization by an Agency approved Pre-Admission reviewer utilizing the Agency’s Level of Care Criteria for State Facility Services. State facility services shall be provided in any MDCH designated facility for the treatment of children, adolescents, adults and older adults with mental illness, severe emotional disturbance and developmental disability. 46 Outpatient Partial Hospitalization Admissions and Continued Stay for Children, Adolescents, Adults and Older Adults: Each MCPN will provide prior authorization by an Agency approved preadmission reviewer utilizing the MDCH Level of Care Criteria for Outpatient Partial Hospitalization. Specialized Residential Admission and Continued Stay for Children and Adolescents in Child Caring Institutions: The Agency requires that all residential services rendered by licensed child caring institutions be prior authorized with the exception of Intensive Crisis Residential services or services in Juvenile Detention Facilities. The MCPNs will provide prior authorization for this level of care utilizing the Agency’s Level of Care Criteria and an Agency approved preadmission reviewer. In the event, medical necessity criteria are not met and inpatient admission or other high acuity service is not medically necessary, request for prior-authorization is denied. A less non-residential alternative may be recommended, or, if no need for CMH services is identified, the applicant may be referred to resources outside of the Agency/ MCPN network. Denial of Authorization for Care An Agency approved preadmission reviewer (PAR) may authorize a specific level of care. However, only an Agency approved PAR who is a physician may deny services. The physician reviewer must discuss the clinical merits of the request with the physician/provider prior to issuing a denial. All pertinent clinical information must be obtained and reviewed as part of this process. When a denial is issued, the provider is notified verbally and in writing and the consumer is notified in writing. The notification must inform the provider and consumer of clear information regarding the reasons for the denial and the availability of the UM appeal process. Services may not be denied solely based on preset limits of the cost, amount, scope and/or duration. Instead, determination of the need for services shall be conducted on an individualized basis. Pre-Admission Review and Utilization Management Staff It is a requirement that all staff performing pre-admission reviews and/or utilization management functions pertaining to prior authorized services including initial/continuous reviews, appeals and denials, must be credentialed and recredentialed. The credentialing process defined by the Agency and described later in this manual, ensures that each provider, directly or contractually engaged, meets at least MDCH licensing, training and scope of practice, contractual and Medicaid Provider Manual requirements. Individuals who do not maintain appropriate licensing, training and scope of practice shall be immediately removed from the role of a preadmission review screener and/or utilization management decision makers. Inter-Rater Reliability 47 The MCPNs are responsible for utilizing MDCH and Agency Level of Care/Medical Necessity Criteria for authorization of services. In order to ensure consistent level of care determinations, the MCPNs are required to conduct monthly inter-rater reliability reviews for all staff making utilization management decisions and forward this information electronically to the Agency regarding authorizations and/or denials of care. Guiding Principles and Other UM and Delegated Functions The Agency, MCPNs, Coordinating Agencies, and Service Providers should adhere to the following regardless of level of care. The MCPN and CAs are accountable and must oversee any functions it delegates to any sub-contractor. Utilization Management Plans should address these guiding principles: Eligible individuals in need of mental health services including individuals with cooccurring substance use disorders have access to the full continuum of care. Clinically necessary treatment occurs in the least restrictive environment that is available and clinically appropriate. An Individual Plan of Service (IPOS) always guides treatment and includes scope, duration and intensity of services. The IPOS is developed and revised using the principles of person-centered planning. Clinical documentation including no shows and cancellations should be timely and thorough Hospital care is viewed as a point on the care continuum, which provides safety, stabilization, and skilled supervision. Discharge planning of timely, clinically appropriate aftercare is an essential provision for the continuum care that begins at the time of hospital admission or admission to a direct care provider Timely and appropriate ambulatory/outpatient treatment for mental health disorders contributes to expedient symptom reduction. Mental health needs are addressed utilizing available community resources and natural supports. Coordination and integration of care includes sharing of timely relevant clinical information between mental and healthcare providers as necessitated by the eligible person’s health needs. Annual Review of Utilization Management Plans The above entities must also provide an annual evaluation of their Utilization Management Plan to ensure compliance with the Agency, Federal and MDCH expectations. The Access Center and MCPNs UM Plan annual evaluations will review their plan’s effectiveness in facilitating access, managing care, improving outcomes, and providing useful data for resource allocation, quality improvement and other management decisions. Standardized reporting templates for the MCPNs request data on the following areas (may not be all inclusive): 48 Utilization patterns for all levels of care, average lengths of stay, penetration rates for treatment levels compared with State and National Statistics State Performance measures including access, requests for service, readmissions within 30 days(CMHS Uniform Reporting System; State Mental Health Measures) Denials/Reduction in Services Recipient Rights Complaints Customer and/or Provider Satisfaction Behavior Management Plans Sentinel Events Inter-Rater Reliability Measures and Results Performance Improvement Initiatives and Achievements Standardized reporting template for the Access Center requests data on the following areas (may not be all inclusive): Access Center Telephone Statistics MCPN Enrollments and Assignments Call Center Internal Monitoring Satisfaction Surveys Peer Review Crisis Referral and Abandonment Rates Appeals Clinical Appeal Process When a request for a level of care requiring prior authorization is denied, an appeal of that decision is offered to the consumer and provider. Both the consumer and provider may request an appeal. The MCPNs are responsible for distributing and assuring compliance with the Agency’s policies for accessing the clinical appeal process. a. First Level Appeal Upon receipt of a verbal or written request for an appeal by a provider or consumer, each MCPN shall have Agency approved physicians also called Pre-Admission Reviewer (PAR) not involved in the initial denial perform the first level appeal review. Appeals for Inpatient Psychiatric Hospital Services must be available immediately upon request. Appeals for all other levels of care must be completed within two (2) business days of the request. The appeal shall be completed within one (1) business day of the request. Additional clinical information must be requested from the provider and received along with the original request and information. If the original denial is held, the physician or PAR must discuss the clinical merits of the request with the provider prior to issuing the denial. When a denial is issued the provider shall be notified verbally and in writing and the consumer is to be notified in writing. The notification must inform the provider and consumer of the availability of a second level appeal and the process to request that appeal. 49 b. Second Level Appeal Second Level Appeals are performed by the Agency within two (2) business days of request using the UM Agency Second Level Appeal Form (see appeal form in the appendix). The Agency psychiatrists/PAR will notify the MCPN provider/requestor and consumer of the decision within two (2) business days. Once the Agency has completed the appeal, the UR Appeal rights are exhausted. However, consumers are free to request Medicaid Fair Hearings or file Recipient Rights Complaints regarding any denial of services at any time. Reconsideration Reviews and First-Level Appeals When a second level of appeal is required, the case is referred to the Agency, Clinical Services Unit, 8th Floor, Second Opinion A second appeal is an additional clinical evaluation and decision provided response to a request from an applicant, authorized representative or referring mental health professional, in dispute of an adverse decision when: 1) A specific request for inpatient hospitalization has been denied by a psychiatrist reviewer, and 2) Following a face-toface assessment by a qualified professional, determination is made that no mental health service is needed and the applicant is referred outside the Agency network to other human service resources. In the instance of a second opinion at the second level of appeal, the case is referred to the Agency for review and determination. Medicaid Fair Hearings Medicaid Fair Hearing (MFH) also known as Administrative Fair Hearing): is an impartial review process maintained by the Michigan Department of Community Health’s Administrative Tribunal (MDCH/AT), that insures Medicaid beneficiaries or their legal representatives involved in a Community Mental Health Services Program Managed Care Plan have the opportunity to appeal decisions of the Agency or its contractors to deny, suspend, reduce or terminate Medicaid-covered or MDCH-defined services. A Medicaid Beneficiary may request a hearing at any point during the rendering of mental health services or supports Medicaid Fair Hearing Appeal Process The following outlines the required steps in a Medicaid Fair Hearing Process: A Medicaid beneficiary has the right to request a fair hearing when the PIHP or its contractor takes an “action”, or a grievance request is not acted upon within 60 calendar days. The beneficiary does not have to exhaust local appeals before he/she can request a fair hearing. The agency may not limit or interfere with the beneficiary’s freedom to make a request for a fair hearing. The parties to the state fair hearing include the PIHP, the beneficiary and his or her representative, or the representative of a deceased beneficiary’s estate. 50 Advance Notice Whenever services are denied, suspended, reduced or terminated (e.g., services will not be provided as specified in the IPOS), the individual and his or her guardian shall receive the Advance Notice Form, Request for an Administrative Hearing Form and an MDCH/AT business reply envelope . A copy of the signed form shall be placed in the case record. The written notice is required regardless of the reason of reduction, termination, suspension or denial of services (e.g., person moves out of state or the country, or the person indicates they no longer want services). The advance notice must be mailed 12 calendar days before the intended action takes effect. The only exception is where there is credible evidence of death. Adequate Notice Whenever services are denied, suspended, reduced or terminated (e.g., services will not be provided as specified in the IPOS), as a result of an order of the treating physician or to an individual not currently receiving services, the individual and his or her guardian shall receive the Adequate Action Notice form, the Request for an Administrative Hearing form) and an MDCH/AT Business Reply Envelope. A copy of the signed form shall be placed in the case record. Adequate Action Notice shall be provided to each Medicaid beneficiary who is denied requested inpatient hospitalization (including when alternate services are offered and the individual/parent/guardian agrees to these services), or is denied all network services and referred outside the Agency contractor network to other community resources, at the time of the denial. These individuals are also entitled to a second opinion according to the Michigan Mental Health Code. The MCPN or Direct Contract Provider shall arrange for a Second Opinion within the network or outside the network at no cost to the beneficiary. The Adequate Action Notice is given to the consumer at the time the action is taken and should always be part of the process of developing an Individualized Plan of Service/Person Centered Plan. Expedited Hearings Expedited hearing is available when it is determined that following the standard timeframe could seriously jeopardize the beneficiary’s life or health or ability to attain, maintain, or regain maximum function, Medicaid Beneficiaries must be given instructions for accessing the Medicaid Fair Hearing Process. An addressed stamped envelope provided to the Medicaid Beneficiary and the completed form is mailed to: STATE OFICE OF ADMINSTRATIVE HEARINGS AND RULES MICHIGAN DEPARTMENT OF COMMUNITY HEALTH ADMINISTRATIVE TRIBUNAL P.O. BOX 30763 51 LANSING, MI 48909-9951 Discharge Planning Discharge planning begins at the time of admission and is an ongoing process throughout the course of treatment for all levels of hospital-based care. Appropriate discharge and aftercare planning are important to the successful management of behavioral health care services. The MCPNs and its subcontractors are expected to actively plan for discharge of Consumers in inpatient settings. The Plan should include: Involvement of the Consumer and the family in plan development, Brief summary of the diagnosis and course of treatment, Identification and confirmation of natural supports and available, appropriate community resources, Recommendations for the next level of care as Consumer move to a less restrictive environment, Initial aftercare appointment, and Description of course of treatment, restrictions, if any and planned final disposition. Note: a psychiatrist must see a consumer within seven (7) days following an inpatient stay or partial hospitalization. Out-of-Network Services In an emergency (using "reasonable-person" standards), consumers may access services at any provider or facility, in- or out-of-network. When the consumer’s condition is stabilized, the MCPN works with the consumer and the out-of-network provider to transition the consumer to a network subcontractor. Additionally, when services cannot be provided within the 30 minutes or 30 miles access standard, (e.g., a child in foster care outside Wayne County), the MCPN must make arrangements for services in the local area in which the person is residing. The MCPNs and CAs must ensure that costs to the beneficiary shall be no greater than they would be if the services were furnished within the network. The MCPNs and CAs are responsible for communicating this protocol in writing to all out of network providers. Intensive Care Management Program As part of the Agency’s Utilization Management Program, the MCPN is conducting an intensive telephonic outreach and monitoring individuals who have high utilization of authorized services. The MCPN will contact the consumers, providers, and MCPNs to ensure and support, continuity of care, and full implementation of Person-Centered Planning. 52 Managing Co-Occurring Substance Use Disorders (SUDs) The MCPN and other network providers are responsible for providing and ensuring that needed substance abuse treatment services are available to Consumers. MCPNs must have providers within their networks who are capable of treating individuals with SED, SMI, and DD who also have co-occurring substance abuse disorders (SUDs). The DCPs must also have the capability to treat consumers with co-occurring SUDs. Traditionally, these individuals are not best served in programs whose sole focus is treatment of SA disorders. It is expected that the MCPNs and DCPs develop integrated programs where mental health and substance abuse treatment occur in the same treatment setting. From time to time individuals may appear for screening or in treatment that are more appropriate for traditional substance abuse services, e.g., an individual who is an injection drug user and requires methadone treatment. In such cases, when the psychiatric condition will not interfere with the psycho-educational model, such individuals should be referred to the City of Detroit Bureau of Substance Abuse at 1-800467-2452 or 1-313-876-4562 and Southeast Michigan Community Alliance (SEMCA) at 1800-688-6995 or 1-800-688-6543. Managing Consumers with Co-Occurring SED, SMI, and/or DD The Agency expects that MCPNs and other network contractors are responsible for the provision of services to Consumers with co-occurring mental illness and developmental disabilities. MCPNs and subcontractors must have an integrated approach and model to treat and manage Consumers with these disorders. Services include ambulatory, residential and hospital-based services Coordination with Other Human Service Organizations The Agency network providers are required to coordinate with other health and human services and criminal justice systems in the community. Coordination of care ensures effective service planning, can improve member outcomes, and conserve resources. These systems include education, public health, child and adult protective services, the courts, juvenile and adult probation as well as appropriate providers such as shelters . The MCPNs, subcontractors, and DCPs are required to maintain coordinating agreements with public partners. The purpose of these agreements is to develop procedures and protocols for mutual referrals, continued coordination of services, and follow-up to ensure services are being provided as expected. Medicaid Health Plans In addition to general medical services provided as a part of the Medical Services Administration Comprehensive Health Care Program, the Medicaidcontracted Health Plans (MHPs) are responsible for the following non-specialized mental health services: Screening for behavioral health disorders during wellness checks for adults. Early Periodic Screening Diagnosis and Treatment (EPSDT) exams for children that include age-appropriate medical, developmental, and mental health evaluations. All other medical transportation including: 53 Behavioral health services provided by primary care physicians, or other applicable Medicaid physicians within the scope of their licenses. Behavioral health services provided by federally qualified health centers and rural health clinics. Ambulatory, laboratory, pharmacy, diagnostic testing services for Medicaid eligible individuals. Medical/surgical services for Medicaid beneficiaries in acute community psychiatric hospitals, other than the physical examination which is the responsibility of the MCPN. Physician or facility services in a medical/surgical emergency room prior to stabilization of the psychiatric crisis. Pharmacy for Medicaid recipients. Medicaid Health Plan 20 visits (limited non-specialized mental health benefits). Occupational Therapy, Physical Therapy Services for General Medical Conditions (e.g., stroke, heart attack). MCPNs must have agreements with the MHPs. Those agreements must describe in detail the operational policies, procedures and protocols for referrals and treatment coordination for the Consumers. MCPNs may obtain the name of the Consumer’s MHP by contacting Medifax, the MSA’s Medicaid eligibility verification system. Note: not all Consumers are enrolled in Medicaid. To confirm Medicaid eligibility, the MCPN or its subcontractors may check CMH LINK or access the State’s Medicaid eligibility roster through State directed sources. Other Primary Care Providers MCPNs and subcontractors must identify the Consumer’s primary health care provider. If the Consumer does not have a general medical primary care provider, the MCPN should assist the Consumer in obtaining a primary care provider and age appropriate general medical services. The MCPN is expected to be familiar with the medical services offered in Wayne County and identify a primary care provider by doing the following: Contact the Consumer’s insurance company ( MHP, Medicaid, BCBS, HMO) for a selection of primary care providers, Arrange appointment with physician, Arrange transportation to physician’s office, if needed, Contact local public health department or other organizations that provide no cost or low cost care, and Have available local medical professional resources and telephone numbers that offer low cost or no cost care. The MCPNs’ subcontractors and the DCPs must document coordination of care with the Consumer’s Primary Care Provider in the member record. 54 Early Periodic Screening, Diagnosis Treatment Early Periodic Screening, Diagnosis and Treatment (EPSDT) and Comprehensive Care Services (EPSDT-CCS) is a Medicaid program administered by the MHPs and certain fee-for-service (FFS) primary care providers. This preventive health program provides initial and periodic examinations and screening and medically necessary follow-up care for the correction of physical, mental health, and substance abuse conditions. The MHPs and Medicaid FFS primary care providers are responsible for EPSDT services. MCPNs subcontractors and the DCPs must ensure that all Medicaid-eligible individuals under age 21 receive the EPSDT services. MCPNs, subcontractors and DCPs are required to accept referrals from the MHPs and primary care providers for the provision of specialty mental health, development disability and substance abuse services for Consumers identified as needing such services during the screening process. MIChild MIChild is an MDCH health insurance program for low-income families covering general medical, mental health, and substance abuse services. The general medical services are provided by the MHPs. The MCPNs and the DCPs are required to provide mental health services and coordinate substance abuse treatment with Coordinating Agencies for children and adolescents enrolled in the MIChild Program. There are no mental health benefits provided by the Qualified Health Plans for children enrolled in the MIChild Program. Therefore, the MCPNs have responsibility for the full array mental health services required by these individuals including Consumers not in the priority population. For additional information, contact Development Centers, Inc. Children’s Special Health Care Services Program Children’s Special Health Care Services (CSHCS) Program (formerly Crippled Children’s Program) is a federally (Department of Health and Human Services Maternal Child Health Block Grant, Social Security Act, Title V) and state-funded program. The program is designed to provide general medical care and limited mental health benefits for minors up to age 21 with diagnoses including diabetes, muscular dystrophy, cerebral palsy, spina bifida, and HIV/aids. The MCPN, network contractors and DCPs are required to refer and/or coordinate services with this program. For more information contact: MCDH Family Phone Line: 800-359-3722 Medical documentation from a specialist regarding the chronicity and severity of the illness and treatment plan may be mailed to: MDCH Review and Evaluation Division 55 Customer Support Section P.O. Box 30734 Lansing, MI 48909-8234 Children’s Special Health Care Detroit Department of Health and Wellness Promotion- City of Detroit Residents 313-876-0180 Children’s Special Health Care Wayne County Health Dept. – Excluding City of Detroit 734-727-7088 To select or request a different MHP contact: Michigan Enrolls 877-274-2737 For coordination of care issues or questions contact: Children’s Choice 800-566-1110 Kid’s Care 888-588-8543 Basic Health Plan – contact the Consumer's Primary Care Provider Wayne County HealthChoice Wayne County HealthChoice is a medical assistance program for low income, residents of Wayne County, age 21 through age 64. Two vendors provide the healthcare services (Ultimed and HealthSource). The PlusCare program does not provide any mental health benefits or psychotropic medications for their enrollees. The MCPNS must provide mental health services and psychotropic medications for individuals enrolled in this program who are Consumers. For information contact: Wayne County Plus Care 313-833-3450 Patient Care Management System 640 Temple – Suite 370 Detroit, MI 48201-2558 Substance Abuse Coordinating Agencies Substance Abuse services for Wayne County residents are accessed through one of two Coordinating Agencies. Southeast Michigan Community Alliance (SEMCA) is the Coordinating Agency for Wayne County, excluding the City of Detroit. The Detroit Department of Health and Wellness Promotion, Bureau of Substance Abuse, Prevention, Treatment and Recovery (DHWP/BSAPTR) is the Coordinating Agency for the City of Detroit. The services provided by these Agencies are for Medicaid and indigent Consumers only. The following services are available: Assessment, Diagnosis, Placement, and Referral, Outpatient Services: 56 Individual Therapy Family Therapy Group Therapy Intensive Outpatient Services: With Domicile Without Domicile Residential (subacute) Detoxification, Residential Services, and Food and Drug Administration (FDA) approved controlled substances (e.g., Methadone, Levo-Alpha-Aceto, etc.). In order to participate in the City of Detroit, Bureau of Substance Abuse, Prevention, Treatment and Recovery Medicaid Managed Care Program, an individual must: Have recognized, appropriate identification (i.e., State of Michigan Identification, birth certificate, Social Security card, etc.). Be a resident of the City of Detroit whose Medicaid service case is currently held in the City of Detroit Region as identified by the recipients Medicaid Card or Medicaid case file only. (City of Detroit residents have priority for substance abuse treatment within the City of Detroit region) Access to care for Substance Abuse recipients entering the Detroit Region can be facilitated through any of the following entry points: Central Diagnostic and Referral (CDRS) Service-Adults and adolescents. Calling the region’s Toll Free Access Management System (AMS)-Adults and adolescents – 1-800-467-2452. Southeast Michigan Community Alliance (SEMCA) services Wayne County residents outside the City of Detroit. In order to participate in the SEMCA Medicaid Managed Care Program, an individual must: Have recognized, appropriate identification (i.e., State of Michigan Identification, birth certificate, Social Security card, etc.). Be a resident of Wayne County outside the city of Detroit whose Medicaid service case is currently held in the Wayne County Region as identified by the recipients Medicaid Card or Medicaid case file only. (Wayne County residents have priority for substance abuse treatment within the Wayne County Region.) Access to care for Substance Abuse recipients entering the Wayne County Region can be facilitated through any of the following entry points: Central Diagnostic and Referral (CDRS) Service-Adults and adolescents. Calling the region’s Toll Free Access Management System (AMS)) Line- Adults and adolescents – 1-800-686-6543. 57 Table I: D-WCCMHA System Delegated Functions Medicaid Managed Care Functions UTILIZATION MANAGEMENT Access & Eligibility Determination Level of care assessment service/support selection Managers of Comprehensive Provider Networks (MCPNs); Access Center-Pioneer and Coordinating Agencies (CAs) & Service authorization Utilization Review CUSTOMER SERVICES Information services Complaint, Processes Grievance and Community Benefit PROVIDER NETWORK MANAGEMENT Network development Network policy development Credentialing and Privileging QUALITY MANAGEMENT Standards setting Performance measurement Appeals Pioneer Behavioral Health, BSAPTR SEMCA MCPNs: Care Link; Consumer Link; Gateway; Community Living Services (CLS); Synergy Partners; Coordinating Agencies: Bureau of Substance Abuse, Prevention Treatment and Recovery (BSAPTR), South East Michigan Community Alliance (SEMCA); Access Center-Pioneer MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners, BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners Providers BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA; Access Center-Pioneer MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSA, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSA, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners Pioneer Behavioral Health Services, BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA 58 Medicaid Managed Care Functions Regulatory management or corporate compliance Medicaid Managed Care Functions Managers of Comprehensive Provider Networks (MCPNs); Access Center-Pioneer and Coordinating Agencies (CAs) MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA MCPNs/ASO and CAs QUALITY ASSURANCE Managing Review processes MCPNs: Care Link; Consumer Link; CLS; Gateway and Synergy Partners BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA Provider education and training FINANCIAL MANAGEMENT Financial operations management and risk MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA review MCPNs: Care Link; Consumer Link; CLS; Gateway; and Synergy Partners BSAPTR, SEMCA Claims management INFORMATION SYSTEMS MANAGEMENT Encounter and performance reporting GENERAL MANAGEMENT Other function(s) None D-WCCMHA SYSTEM DELEGATED FUNCTIONS 59 Credentialing 60 Credentialing D-WCCMHA Credentialing The Agency credentialing process is applicable to MCPNs, Sub-Contractors, Direct Contractors, and CAs. The credentialing process must include primary source verification of the following: Licensure or certification Board certification, if applicable, or the highest level of credential attained; and Medicare /Medicaid sanction. The Agency and its Credentialing Verification Organization (CVO) is responsible for the oversight of standards and processes which guide the credentialing/re-credentialing process for employment of individual practitioners and pre-admission reviewers. Pioneer Behavioral Health is the Agency’s CVO. The Agency/CVO requires that organizations and individuals directly or contractually employed meet all applicable licensing scopes of practice, contractual and Medicaid Provider Manual requirements for appropriate credentialing and re-credentialing. The Credentialing/Re-Credentialing process is required to verify that qualifications of practitioners are consistent with national credentialing standards and applicable laws. The Agency’s Credentialing Committee shall provide oversight of the Credentialing and Re-Credentialing Process which includes the following activities: a) Development and update of credentialing criteria as needed, consistent with Agency, federal, and other State requirements and relevant professional standards b) Review and final decision making for appeals of adverse credentialing decisions made by contracted providers with the network c) Ensuring adherence to timely appeal standards for adverse credentialing decisions which include reconsideration of appeal decisions in writing within 30 calendar days of receipt of an appeal request, and referral to the Agency’s Credentialing Committee for final appeal decisions. d) Developing and monitoring adherence to established time lines for the credentialing process e) Determining, as needed, the utilization of participating providers to ensure all relevant information is incorporated in credentialing/recredentialing decisions. f) Maintaining oversight of the CVO, and the contracted provider network’s implementation of the credentialing, and recredentialing process, which includes the right to approve, suspend, or terminate contracted providers selected by the MCPN’s, their sub-contractors, Direct Contractors, or CA’S. 61 g) Granting temporary or provisional credentials, based upon a specific community/consumer need. Individual Practitioners MCPNs, Sub-contractors, CAs, and Agency Direct Contractors must develop policies and procedures for credentialing and re-credentialing individual practitioners which shall include at least the following; Physicians (MDs and D.O.’s) Physicians Assistants Psychologist (licensed, Limited License, and Temporary License) Licensed Master’s Social Workers, Licensed Bachelor’s Social Workers, Limited License Social Workers and Registered Social Service technicians Nurse Practitioners, Registered Nurses, and Licensed Practical Nurses Occupational Therapists and Occupational Therapist Assistants Physical Therapists and Physical Therapist Assistants Speech Pathologists Licensed Professional Counselors Primary Source Verification Primary Source Verification is comprised of primary source verification of: Licensure or certification Board Certification, or highest level of credentials attained if applicable, or completion of any required internships/residency programs, or other postgraduate training. Documentation or graduation from an accredited school National Practitioner Databank (NPDB)/Healthcare Integrity and Protection Databank (HIPDB) query or, in lieu of the NPDB/HIPDB query, all of the following must be verified: Minimum five-year history of professional liability claims resulting in a judgment or settlement; Disciplinary status with regulatory board or agency; and Medicare/Medicaid sanctions. If the individual practitioner undergoing credentialing is a physician, then physician profile information obtained from the American Medical Association or American Osteopathic Association may be used to satisfy the primary source requirements of (a), (b), and (c) above. Credentialing and Re-Credentialing Process Compliance with Federal requirements prohibit employment or contracts with providers excluded from participation under either Medicare or Medicaid. A complete list of Centers for Medicare and Medicaid Services (CMS) sanctioned providers is available on their website at http://exclusions.oig.hhs.gov. A complete list of sanctioned providers is available on the Michigan Department of Community Health website at www.michigan.gov/mdch. (Click on Providers, click on Information for Medicaid Information for Medicaid Providers, click on List of Sanctioned Providers). This review of provider status shall be performed at least every two years. 62 Health Care Professionals shall not be the subject of discrimination solely on the basis of license, registration or certification; or as a result of serving high-risk population who specialize in the treatment of conditions that require costly treatment. All findings from the Quality Assessment Performance Improvement Program are submitted to the chair of the Agency’s Credentialing Committee (Agency Medical Director) and incorporated in all re-credentialing decisions. Maintenance of complete individual credentialing/re-credentialing files for all credentialed providers which include: the initial credentialing and all subsequent re-credentialing applications; information gained through primary source verification; and all other pertinent information used in determining whether or not the provider met the PIHP’s credentialing and re-credentialing standards. Inform the applicant in writing of the reasons for any adverse credentialing/recredentialing decision to deny, suspend, terminate the contract for any reason other than lack of need, and their right to appeal the process (consistent with state and federal regulations). Delegated Credentialing The Agency’s credentialing and re-credentialing process requires the following provisions: The MCPN, Sub-Contractor, Direct Contractor, or CA can delegate credentialing of professionals to the organization/facility where the individuals work. The MCPN is responsible for ensuring that the organization/facility meets credentialing standards. If the PIHP delegates to another entity any of the responsibilities of credentialing/re-credentialing or selection of providers that are required by the Credentialing/Re-Credentialing policy, it must retain the right to approve, suspend, or terminate from participation in the provision of Medicaid funded services a provider selected by that entity and meet all requirements associated with the delegation of PIHP functions. The PIHP is responsible for oversight regarding delegated credentialing or re-credentialing decisions. CVO Credentialing Responsibilities The Agency’s CVO is responsible for ensuring compliance with credentialing and re credentialing policy and standards identified in the Agency and MDCH policy and process which includes: Requiring that professionals have a minimum standard of no less than 24 hours per year of ongoing in-service training and/or continuing education related to the provision of services to the specific population group which clinicians serve. Ensuring that clinicians provide care within the scope allowed by the professional’s license, and determined by their training and supervisory experience. Maintain a common, centralized credentialing process that includes: o Credentialing and re-credentialing for the following entities, 63 o o o Utilizes Agency staff directly involved in clinical review/utilization review as needed. Includes appropriate professionals throughout initial and on-going credentialing activities such as child mental health professionals and pre-admission reviewers. Has provisions to review and oversee services provided by nonaccredited direct contractors. Initial Credentialing Process Policies and procedures for the initial credentialing of individual practitioners require a written application that is completed, signed, and dated by the provider and attests to the following elements: Lack of present illegal drug use. Any history of loss of license and/or felony convictions. Any history of loss or limitation of privileges or disciplinary action. Attestation by the applicant of the correctness and completeness of the application. An evaluation of the provider’s work history for the prior five years. Temporary/Provisional Credentialing of Individual Practitioners The Credentialing and Re-Credentialing process ensures provisions for granting temporary or provisional credentials. Temporary or provisional credentialing shall not exceed 150 days. A decision regarding rendering temporary or provisional credentials shall be made within 31 days of receipt of a complete application. The following minimum documents shall accompany a signed application for temporary or provisional credentialing: Lack of present illegal drug use. History of loss of license, registration, or certification and/or felony convictions. History of loss or limitation of privileges or disciplinary action. A summary of the provider’s work history for the prior five years. Attestation by the applicant of the correctness and completeness of the application. Deemed Status Individual practitioners or organizational providers may deliver health care services to more than one PIHP. A PIHP may recognize and accept credentialing activities conducted by any other PIHP in lieu of completing their own credentialing activities. In those instances where a PIHP chooses to accept the credentialing decision of another PIHP, copies of the credentialing PIHP’s decision shall be maintained in administrative records of the Agency’s Credentialing Committee. 64 Re-Credentialing Individual Practitioners The re-credentialing process for physicians and other licensed, registered, or certified health care providers shall include, at minimum, the following requirements: Re-Credentialing at least every two years. An update of information obtained during the initial credentialing A process for ongoing monitoring, and intervention if appropriate, of provider sanctions, complaints and quality issues pertaining to the provider, which must include, at minimum, review of : o Medicare/Medicaid sanctions o State sanctions or limitations on licensure, registration or certification. o Member concerns which include grievances (complaints) and appeals information o PIHP Quality issues Criminal Background Checks Ensure all required staff remains in Good Standing with the Law. All employees, contractors, and consultants hired to provide professional or direct care services to consumers receiving mental health services must: Be in good standing with the law (i.e., not a fugitive from justice, a convicted felon, or an illegal alien). Pass successfully the required criminal background checks, completed in accordance with Federal, State of Michigan or contractual requirements. Reporting Improper Conduct D-WCCMHA is committed to ensuring that all required staff and contractors remain in good standing with the legal and professional standards of conduct. All employees, contractors, and consultants hired to provide professional or direct care services to consumers are obligated to follow prevailing regulations and all standards as outlined in this Provider Manual and in the D-WCCMHA provider contract. D-WCCMHA Credentialing Committee There are numerous resources available to assist the D-WCCMHA network in meeting the challenge of performing expected duties and responsibilities. Readers of this document should refer to the Customer Service, Network Management, and the Compliance sections of this Manual for specific details. D-WCCMHA maintains a Credentialing Committee which meets on a monthly basis. The Credentialing Committee can be accessed for questions and concerns during regular Agency business hours by calling the Customer Service Department. 65 Required Training 66 Required Training The Agency goal is to work toward advancing the development and maintenance of a highly skilled and competent workforce. In 2008, the Agency launched the Virtual Center for Excellence (VCE) website. This multimedia website provides 24/7 training opportunities for the CMH workforce. One of the key objectives of this website is to provide convenient and easily accessible event listings, online registration and archive of video recorded lectures and distance learning opportunities. Members have the benefit of a virtual transcript which tracks registration and attendance. Using proven evidence based practices; VCE offers the most current trainings and curriculums in the field to advance the knowledge and skill of the workforce. The Agency authored a “Community Mental Health Workforce Required Training” manual and a grid which lists all trainings required for members of the CMH workforce, a description of the training, the target source of the training, the target audience, and how often the training must be taken. The following trainings are mandated for not only clinicians but the entire CMH workforce and available through the VCE: Recipient Rights Recipient Rights Update HIPAA Medicaid Fair Hearing Medicaid Fair Hearing Update Person Centered Planning Initial face to face training at hire at Agency Every 2 years after hire At hire and biennially At Hire Every 2 years after hire At hire and every 2 years after Please see the Community Mental Health Workforce Required Training manual and grid for other mandated trainings that may be completed at other locations. (Appendix X) 67 Network Management 68 Network Management / Contract Management Network Administration / Contract Management The Agency has assigned a full time mastered prepared staff person (network administrator/contract managers), to support each MCPN and Direct Contract provider organization (DCP). The Network Administrator/Contract Manager is responsible for: Receiving and responding to operational requests and inquiries of the MCPN and DCP; Assisting the MCPN and DCP in resolving inter-network programmatic issues; Providing and/or arranging for technical assistance, training, resource materials and other supports to assist the MCPN and DCP in complying with the terms and conditions of the Contract; Advising the MCPN and DCP of changes, revisions, and/or corrections to instructions, policies, procedures, guidelines, and protocols applicable to the Contract; and Assuring that the MCPN and direct contract providers comply with the Agency’s contract performance expectations. The Agency expects the key leaders and staff of the MCPN and DCP to meet with its Network Administrator/Contract Manager(s) on a periodically scheduled basis. Additionally, the MCPN and DCP may designate individual(s) as point(s) of contact for the Network Administrator/Contract Manager. The MCPN and DCP staff/contact person is responsible for: Responding to all inquiries from the Agency in a timely manner; Assisting the Network Administrator/Contract Manager in resolving inter and intra network issues; Coordinating participation in Agency offered or sponsored trainings; Advising the appropriate parties within the MCPN or DCP network of changes, revisions, and/or corrections to Agency instructions, policies, procedures, guidelines, and protocols applicable to the Contract; and Assisting/implementing the required policies, procedures and/or Agency instructions. MCPN Subcontractor(s) MCPN’s legal agreements with their subcontractors must, at a minimum, require 120 days notice of termination without cause for either party. If a subcontractor terminates from the MCPN network or is terminated by the MCPN from its network, the MCPN must notify the Agency immediately upon receipt of or issuing a termination notice. Termination notice should be forwarded to the Agency’s Legal Division and a copy sent to the Network Administrator/Contract Manager. 69 The MCPN’s contracts must provide a means for immediate termination of a provider for cause. MCPNs must notify the Agency immediately upon issuing a termination notice for cause. Additionally, the MCPN must have a process of appeal and review for subcontractors terminated. Disagreements between the MCPN and its subcontractors should be resolved between the two parties. The Agency expects that the MCPN will utilize all available resources to resolve disputes, including mediation and requesting technical assistance from the Agency, in such a manner that it does not disrupt services. If the Agency becomes aware of pattern of disputes that will impact the delivery network, the Agency reserves the right to intervene to ensure a resolution of issues and no disruption of service for consumers. Any costs incurred with regard to any dispute resolution are the responsibility of the MCPN and its subcontractor. MCPN Conflicts Disagreements between the MCPNs should be resolved between the two parties. If the MCPNs are unable to resolve a dispute, the Agency will review written documentation of the issue from both parties, including the documentation of attempts to resolve the issue, and determine an equitable solution. In the most complex situations, the Agency or its designee, (e.g., a mediator) may request that the parties present the issue in person to the Agency. The Agency will communicate its determination to both parties within ten (10) business days. If the situation demands an urgent resolution, the Agency will communicate its decision as soon as possible, but in no case will the determination be greater than 24 hours following receipt of the information. MCPN and Other Publicly Funded Human Service Organizations Should an MCPN or its subcontractors have difficulty coordinating services with other publicly funded human services organizations that cannot be resolved, the MCPN should seek technical assistance from the Agency. The MCPNs may contact their respective Network Administrator/Contract Manager to request technical assistance. The Agency will review written documentation or related materials and intervene as appropriate with the funding source to facilitate a resolution. Staffing Standards MCPNs and their subcontractors must have staffing standards, policies and procedures, and hiring practices that ensure appropriate, qualified staff are providing services to consumers. The MCPN must ensure that its subcontractors conduct criminal background checks on all professional and nonprofessional individuals hired by the MCPN or its subcontractor in accordance to Agency policies and the State’s guidelines for health care workers. MCPNs and DCPs must ensure that no Consumers with criminal histories are hired at any direct care level within the organization or network. MCPNs and DCPs must review evidence of criminal background check on all employees responsible for delivery of direct care services to consumers. 70 For additional information, refer to the Credentialing section of this manual. Directory The MCPN must produce, maintain and distribute a current directory of its subcontractors to consumers. The directory must include: provider name, address, phone number, picture or logo, type of practice, emergency contact numbers, 24 hour screening centers numbers and locations, and other professional services offered and applicable practice restrictions. Directories must be updated periodically as significant network changes occur, but in any case, no less than annually. Current directories must be provided to each MCPN network administrator. The MCPN directory must clearly identify the Detroit-Wayne County Community Mental Health Agency and its relationship to the MCPN. The MCPN shall not, and shall ensure that its subcontractors do not, reference the Agency in any publicity, advertisements, notices, or promotional material or any announcement to Consumers, including the Provider Directory, without prior review and written approval of the Agency. 71 Quality Management / Improvement Program 72 Quality Management/Improvement Program Quality Improvement Program Requirements Each MCPN must have a written Quality Assurance Performance Improvement Program (QAPIP) which reflects the requirements of the Balanced Budget Act (BBA) and the MDCH standards for internal quality assurance mechanisms. These standards are based upon the "Guidelines for Internal Quality Assurance Programs" (MDCH Contract, FY 11/12) These requirements reflect the standards as identified by the Center for Medicare and Medicaid Services (CMS, formerly know as the Health Care Financing Administration) draft ""Standards and Guidelines for Review of Medicare and Medicaid Managed Care Organizations." (December 22. 1997) The QAPIP must specify the minimum following elements: Element I: Quality Improvement Program The MCPN shall have a Quality Assurance Performance Improvement Program( QAPIP) that achieves, through ongoing measurement and intervention, improvement in aspects of clinical care and non-clinical services that can be expected to affect consumer health status, quality of life, and satisfaction. A. The MCPN has a written description of its QAPIP: The written description contains a detailed explanation of the structure of the QAPIP system and a set of QAPIP objectives that are developed annually and include a timetable for implementation and accomplishment. The plan must evaluate the QAPIP program at least annually. B. Scope: The written QAPIP includes a description for how the organization will assure that all demographic groups, care settings, and types of services are included in the scope of the QAPIP. C. The QAPIP must document specific improvement activities: The QAPIP must contain the following elements: 1. The process for the identification and selection of aspects of clinical care and non-clinical services to be monitored and considered for process improvement projects; 2. The methods used to gather, analyze, report, and utilize customer satisfaction information; complies with the Agency’s MCPN Monitoring Plan 3. A written Critical Event/Sentinel Events process according to Agency guidelines. 4. A process of verification of whether services reimbursed by Medicaid were actually furnished to recipients by affiliates (as applicable), providers, and subcontractors. 5. The mechanisms that will be used to evaluate and annually revise the QAPIP written plan. 6. The responsibilities of the governing body, executive director, medical director, managers, direct staff and subcontracting agencies in the QAPIP process. 7. The structure responsible for performing QAPIP functions and assuring that program improvements are occurring within the MCPN. This committee or other structure must: 73 8. 9. 10. Demonstrate that it meets with a frequency that is sufficient to show that the structure/committee is following up on all findings and required actions. Establish parameters for the role, structure and function of the quality management committee. Maintain records documenting the committees, activities, findings, and recommendations. Include a chart of the Quality Management organizational structure, which allows for clear and appropriate administration and evaluation of the QAPIP. The chart must show a relationship to the Detroit-Wayne County Community Mental Health Agency. Continuous Activity -The QIP provides for continuous performance of quality improvement activities, including tracking of issues over time. Follow Through -The QIP must delineate the mechanisms or procedures to be used for adopting and communicating processes and outcome improvements. Focus on Health Outcomes -The plan must address the role for mental health outcomes to the extent possible within existing technology. Element II: Systematic Process of Quality Assessment and Improvement The QAPIP objectively and systematically monitors and evaluates the quality and appropriateness of care and service to members through quality assessment and performance improvement projects, related activities, and pursues opportunities for improvement on an ongoing basis. The QAPIP has written guidelines for its quality-related activities, which includes specification of clinical or health services delivery areas to be monitored. The monitoring and evaluation of care reflects the populations served by the MCPN in terms of age groups, disease categories, and special risk status. At its discretion and/or as required by the Agency, the MCPN also monitors and evaluates other important aspects of care and service. Use of Quality Indicators: 1. 2. 3. The MCPN identifies and uses quality indicators that are objective, measurable, and based on current knowledge and clinical experience. Indicators shall include, but not be limited to those selected by the DetroitWayne County Community Mental Health Agency. Data collection is used to detect the need for and implement program change. Use of Clinical Care Standards/Practice Guidelines: 1. When there are nationally accepted or mutually agreed upon clinical standards/practice guidelines, QAPIP activities monitor quality of care against those standards/guidelines.; i.e. ACT Fidelity Field Guide, the Dual Diagnosis Capability in Addiction Treatment (DDCAT) and/or Dual Diagnosis 74 2. Capabable (DCC) or Duakl Diagnosis Capability in Mental Health Treatment (DDCMHT) When guidelines exist, a mechanism is in place for continually updating the standards/guidelines. Implementation of remedial action plans: 1. 2. The QIP requires that appropriate remedial actions be taken whenever inappropriate or substandard services are furnished as determined by substantiated recipient rights complaints, customer service reviews, clinical indicators, or clinical care standards or practice guidelines where they exist. Follow-up remedial actions are documented. Assessment of Effectiveness of Corrective Actions: 1. 2. As actions are taken to improve care, there is monitoring and evaluation of corrective actions to assure that appropriate changes have been made. In addition, changes in practice patterns are tracked. The MCPN assures follow-up on identified issues to ensure that actions for improvement have been effective. Element III: Accountability to the Governing Body Responsibilities of the Governing Body for monitoring, evaluating, and making improvements to care include: A. Oversight of the QAPIP There is documentation that the Governing Body has approved the overall QAPIP and an annual QAPIP report. B. QAPIP Progress Reports The Governing Body routinely receives written reports from the QAPIP describing actions taken, progress in meeting QAPIP objectives, and improvements made. C. Annual QAPIP Review The Governing Body formally reviews on a periodic basis (at least annually) a written report on the QAPIP that includes: Studies undertaken, Results, Subsequent actions, Aggregate data on utilization and quality of services, and Effectiveness of these activities. D. Program Modification 75 Upon receipt of regular written reports from QAPIP the delineating actions taken and improvements made, the Governing Body assures that the Executive Director takes action when appropriate and directs that the operational QAPIP be modified on an ongoing basis to accommodate review findings and issues of concern within the MCPN. Element IV: QAPIP Supervision There is a designated senior executive responsible for the QAPIP program implementation. The organization's Medical Director has an identifiable role in the QAPIP program. Element V: Provider Qualification and Selection The QAPIP contains written procedures to determine whether physicians and other health care professionals, who are licensed by the State and who are employees of the MCPN or under contract to the MCPN, are qualified to perform their services. The QAPIP also has written procedures to ensure that non-licensed providers of care or support are qualified to perform their jobs. The MCPN must have written policies and procedures for the credentialing process that includes the organization's initial credentialing of practitioners, as well as its subsequent re-credentialing, recertifying and/or reappointment of practitioners. These procedures must describe how findings of the QAPIP are incorporated into this re-credentialing process. The MCPN must also ensure: 1. Staff possess the appropriate qualifications as outlined in their job descriptions, including the qualifications for all the following: Educational background; Relevant work experience; Cultural competence; Certification, registration, and licensure as required by law. Criminal Background Check 2. A program to train new personnel with regard to their-responsibilities, program policies and operating procedures. 3. A program to identify staff training needs and provide in-service training, continuing education, and staff development activities. 4. A description of the active role of providers in the review and analysis of the information obtained from quantitative and qualitative methods. Element VI: Enrollee Rights and Responsibilities The MCPN demonstrates a commitment to treating members in a manner that acknowledges their rights and responsibilities. 76 The MCPN monitors and assures that each individual has all of the rights established in Federal and State law, such as: A written process for informing consumers of the person-centered process; A written process for informing consumers of their rights to a Grievance and an Appeals process and Medicaid Fair hearing; A written process for informing consumers of their right to a second opinion An “Advance Directives” policy that includes a description of applicable state law and provides for supplying adult beneficiaries with written information on advance directives. Information accommodations for consumers with Limited English proficiency. The MCPN conducts periodic quantitative (e.g., surveys) and qualitative (e.g., focus groups) assessments of member experiences with its services. Assessments must be representative of the Consumers served and the services and supports offered. The assessments must address the issues of the quality, availability, and accessibility of care. The MCPN insures the incorporation of consumers receiving long-term supports or services (e.g., Consumers receiving case management or supports coordination) into the review and analysis of the information obtained from quantitative and qualitative methods. . The MCPN informs recipients of service, practitioners, providers and the governing body of assessment results. As a result of the periodic assessments, the MCPN: Takes specific action on individual cases as appropriate; Identifies and investigates sources of dissatisfaction; Outlines systemic action steps to follow-up on the findings Evaluates and reports outcomes Element VII: Utilization Management The Utilization Management Services and Supports section of the Provider Manual discuss basic UM requirements for the MCPNs, CAs and Direct Contracted Providers. 77 78 Dispute Resolution, Grievance, and Appeals Systems (DRGAS) 79 Dispute Resolution, Grievance, (DRGAS) and Appeals Systems The MCPN and its subcontractors are required to provide access to all Dispute Resolution Grievance and Appeals Systems (DRGAS): Recipient Rights Complaints, Recipient Rights Appeals, Grievance, Mental Health Code Second Opinions, Local Appeals for Medicaid Beneficiaries (formerly Local Dispute Resolution), Alternate Dispute Resolution, Mediation, Medicaid Fair Hearings, Financial Determinations Appeals, Reconsideration Reviews, First and Second Level Appeals of NonCertification Decisions: Acute in-patient care, State hospital/facility services, Partial hospitalization, Specialized residential services for children and adolescents, Intensive crisis residential services, and Special needs residential services, Mental Health Code Review of Individual Plan of Service. Each applicant for, or recipient of services within the Agency’s contracted service area must be provided with accessible mechanisms to present concerns, complaints, disputes and recipient rights complaints in a timely and organized fashion. These mechanisms comprise the Local and Alternate Dispute Resolution process. Each process is designed to address dissatisfaction with services through a timely and organized procedure that clearly defines the criteria for accessing the processes. Consumers have the right to pursue several of these options simultaneously. Consumers, providers, or staff members who participate in DRGAS cannot be punished, penalized or in any way harmed for accessing or requesting these processes. Additional information regarding specific processes is described in the following Agency policies: Recipient Rights Second Opinion Medicaid Fair Hearings Local Appeal for Medicaid Beneficiaries Individual Plan of Service/Person Centered Planning 80 These polices will assist the Agency contractors and their subcontractors in implementing DRGAS. The MCPN must have policies and procedures to operationalize uniform access to the DRGAS process. The MCPNs must have a designated person responsible to address issues or appeals timely, record and monitor requests, track aggregate data for trend analysis and report to the Agency as required in performance reporting and to its QI Committee. Local Appeals for Medicaid Beneficiaries There are extensive regulatory requirements that go hand in hand with providing Medicaid Covered Specialty Supports and Services (Medicaid Services) to eligible beneficiaries in Michigan. The following information highlights relevant information in the Local Appeal for Medicaid Beneficiaries Policy, which is to be used for a comprehensive road map related to Local Appeals for Medicaid Beneficiaries. The Due Process Clause of the U.S. Constitution guarantees that Medicaid beneficiaries must be afforded “due process” whenever Medicaid Services are denied, reduced, or terminated. Nothing about managed care changes these process requirements. Due Process includes: Prior written notice of the action; A fair hearing before an impartial decision maker; Continued benefits pending a final decision; and A timely decision, measured from the date the complaints is first made. Consumers of mental health services, who are Medicaid beneficiaries, have various options available to them to resolve disagreements or complaints. There are options under authority of the Social Security Act and its federal regulations, which were significantly expanded through the implementation of the Balanced Budget Act (BBA) of 1997 regarding grievance and appeals for Medicaid beneficiaries who participate in managed care. Under Balanced Budget Act of 1997 (BBA), there is an extensive series of procedural safeguards. The BBA includes regulations that are designed to protect beneficiaries and assure that they are afforded the opportunity to challenge decisions made by contractors who provide Medicaid Covered Specialty Supports and Services. Several options are available to beneficiaries who express displeasure with decisions or situations related to the services and supports they receive. A Local Appeal for Medicaid Beneficiaries (Local Appeal) is just one of those options. The Local Appeals process must ensure that beneficiaries are informed of their rights to due process when a Notice of Action is given. When a service provider of Medicaid Covered Specialty Supports and Services takes an action, beneficiaries have the ability to exercise their rights when they do not agree with action planned or taken. All appeal processes and procedures must apply the following underlying principles: Timely; 81 Fair to all parties; Administratively simple; Objective and credible; Accessible and understandable to beneficiaries and service providers; and Subject to quality improvement review. Appeal procedures must also assure that there is no interference with communication between the beneficiary and service providers as a result of filing an appeal. Beneficiaries who request an appeal must be free from discrimination and retaliation. Guidelines The following is a brief description of the Local Appeal process and the role of parties involved (For more details, please see the Local Appeal Policy): Beneficiary: A consumer of mental health services who is Medicaid eligible for Medicaid Services from the Agency. The beneficiary’s role in the process is to actively participate in the development of a comprehensive Individual Plan of Service (IPOS) and to challenge Actions taken related to the provision of Medicaid Services. The IPOS will serve as authorization for the Medicaid Services determined medically necessary for that beneficiary. Medicaid Services are to be provided in accordance with the IPOS that will specify: Amount; Scope; Duration; and Commencement date for each Medicaid Service. Agency: The Agency is responsible for reviewing Local Appeals upon request of the beneficiary or a legal/authorized representative. Agency staff and a health care professional will complete this impartial review with the appropriate clinical expertise in treating the beneficiary’s condition. Agency will provide a disposition to the beneficiary. The Agency has provided document templates for use by Contractors and offers technical assistance to Contractors related to the policy. Contractors: Contractors are agents who have been contracted by the Agency to provide Medicaid Services to beneficiaries. They are administratively responsible for processes and procedures related to Local Appeals and include: Direct contractors to the Agency, Managers of Comprehensive Provider Networks, (MCPNs), and Substance Abuse Coordinating Agencies. (CAs) 82 Local Appeals Process: Additional Requirements All MCPNs, their subcontractors, and SA providers must adhere to the following additional standards: Assure that the Notice of Action is completed and provided to the beneficiary for each Action (as defined in Local Appeal Policy for Medicaid Beneficiaries). The contractor making the actual coverage determination related to the Action is responsible for providing the Notice. Understand what constitutes a request for a Medicaid covered service. It is not reasonable for beneficiaries to be able to navigate the complex Medicaid Service system independently. Contractors are required to assist the beneficiary by applying the medical necessity criteria for Medicaid cover services based upon their individualized needs. Having a working knowledge of the scope of Medicaid Services prevents inadvertent denials. Notice of Action must be provided when an Action is taken. There are two types of Notice of Action and they are Adequate and Advance. The same letter is used for both but the service provider is responsible for identifying which type of Action and must assure that it is provided to the beneficiary at the appropriate time and for the appropriate reasons. An Action is a decision that adversely impacts a Medicaid beneficiary’s claim for services due to: o o o o o o o o o Reduction, termination, or suspension of a previously authorized service. (Advance Notice must be mailed 12 calendar days prior to the intended Action.) Denial, in whole or in part, of payment for a service. (Adequate Notice must be provided at the time a decision is made.) Denial or limited authorization of a requested service, including the type or level of service. (Adequate Notice must be provided at the time a decision is made.) Failure to make a standard authorization decision and provide notice about the decision in within 14 calendar days from the date of the receipt of a standard request for service. (Adequate Notice must be provided.) Failure to make an expedited authorization decision within three working days from the date of receipt of a request for expedited service authorization. (Adequate Notice must be provided.) Failure to provide services within 14 calendar days of the start date agreed upon during person-centered planning and as authorized by the service provider. The failure to act within 45 calendar days from the receipt of a request for a standard appeal. The failure to act within three working days from the date of the request for an expedited appeal. Failure to provide disposition and notice of the local grievance within 60 calendar days of the request. 83 Understanding the basic components of an Appeal and the contractor’s role in the Appeal process assists with implementation and ongoing reviews for compliance. An appeal is not a punitive measure reflective of the quality of service provided, instead, an appeal should be viewed as an affirmative identification that the beneficiary was provided a clear description of their appeal options which were developed to support individuals in their goals of recovery and resilience. When a beneficiary request assistance to facilitate submitting a “Request for Local Appeal” related to an Action by a contractor, staff must be willing and competent to assist with completing the “Request for Local Appeal” form and further assist the beneficiary with examining their case file and any documents or records that may be considered relevant to the Local Appeal. Each Agency contractor must report all local dispute resolutions (LDR log) and recipient rights complaints (RR log) on the appropriate forms by the 15 th of each month. See the forms section of this Manual. Other information about the grievance process can be found in the Customer Service section. 84 Customer Service 85 Customer Service Overview Customer service is an identifiable function that is responsible for orienting new individuals to the services and benefits available, including how to access services, rights protection processes, helping individuals with problems and inquiries regarding benefits, assisting individuals with, complaint and grievance processes, and tracking and reporting patterns of problem areas for the organization. This requires a system that is available to assist at the time the individual has a need for help, and being able to assist on the first contact if at all possible. Customer Service Office The Detroit- Wayne County Community Mental Health Agency (Agency) is committed to ensuring a culture conducive to understanding the wants and goals of consumers and to meeting them. This is accomplished through the Customer Services Office (CSO). The CSO is responsible for responding to inquiries, creating and distributing resource materials and information, arranging learning opportunities for consumers, and advancing the role of consumers in systems design and service delivery. The CSO is a critical venue for introducing and ensuring accommodation and support for consumer involvement in the system and providing an individual with information that may be necessary to make informed decisions regarding consumer choice. The CSO is also involved in the consumer grievance and appeal system and offers problem resolution services. The CSO works closely with the Agency’s Office of Recipient Rights to ensure appropriate referral and coordination of follow-up of complaints. In addition, the CSO is responsible for the oversight and monitoring of the customer service functions that have been delegated to contractors and subcontractors. Role of the Agency The Agency maintains a CSO and has also delegated the Customer Service functions to the Managers of Comprehensive Provider Networks (MCPNs) and their contracted providers, the CAs, and the DCPs. All parties shall have a comprehensive Customer Service process that meets Agency, federal, and MDCH standards. The Agency shall: a. Provide Systems navigation services, including peer delivered. b. Provide Problem identification, clarification and resolution assistance. c. Direct the prompt handling and resolution of grievance and appeals processes, information, referral, linkage and follow-through. d. Facilitate the processing and resolution of formal grievances. e. Respond to consumers inquiries. 86 f. g. h. i. j. k. l. m. n. Create and distribute resource materials i.e. Consumer handbook and information to MCPN and Contracted Providers, enrollees and potential enrollees. Provide learning opportunities for consumers and participation for consumers in advancing system design and delivery. Participate with consumers, advocacy groups, and/or other relevant community groups in collaborative efforts and events for advancing the rights of people with disabilities. Provide oversight and monitoring of the Agency’s Enhanced Consumer Supported Employment Program. Develop and implement training and structured learning opportunities for consumers, and the staff of the MCPNs and their Contracted Providers, the Coordinating Agencies, and the Director Contract Providers. Develop and promote planned efforts and opportunities for meaningful and valued active involvement and participation of consumers with the Agency, MCPNs, Contracted Providers and/or other organizations in the community system in the following areas: •Governance •Policy development •System assessment, planning and evaluation •Contracting and procurement •Quality assurance, improvement and management; Provide Recipient Rights referral and follow-up coordination. Maintain current listing of all Contracted Providers, the services they provide and alternative languages that are spoken. Provide Agency oversight, for delegated Customer Service functions. Role of the Contractor The MCPNs and their contracted providers are expected to create a culture of good customer service through the provision of information, and learning opportunities and by making every effort to resolve issues with consumers. 1) The MCPN shall maintain an identifiable CSO. Qualified individuals knowledgeable in customer service protocols shall staff the CSO. 2) All Customer Service staff shall be trained on Customer Service standards, policies and procedures within 30 days of hire and annually thereafter. Training shall be provided by Agency approved trainers utilizing Agency approved modules. 3) Customer Service staff will be expected to attend continuing staff training as indicated by the Agency and should be proficient in conflict resolution, consumer advocacy, enrollee rights, grievance and appeals processes and cultural competency. 4) The MCPN shall identify a Customer Service staff as the contact person to serve as a liaison to the Agency’s CSO. The contractor shall provide immediate notification of any changes. 5) The CSO shall be staffed with a minimum of one (1) full time staff dedicated to Customer Services. If any Customer Service function is delegated to Contracted Providers appropriate Full Time Equivalents (FTEs) shall be assigned to sufficiently meet the needs of the people in the service area. 87 6) The CSO shall adhere to all Agency Customer Service Office policies, procedures and standards. 7) The CSO shall: a. Provide systems navigation services, including peer delivered; b. Provide problem identification, clarification and resolution assistance; c. Direction for the prompt handling and resolution of grievance and appeals processes, information, referral, linkage and follow-through; d. Prompt response to all inquiries; e. Distribution of Agency resource materials as indicated by the Agency’s CSO. i.e. Agency Consumer Handbook and brochures; f. Learning opportunities for consumers and participation for consumers in advancing system design and delivery; g. Participate with consumer groups, advocacy groups and/or other relevant community groups in collaborative efforts and events for advancing the rights of people with disabilities; h. Coordinate, participate, track and report on staff training and structured learning opportunities; i. Develop, promote and participate with planned efforts and opportunities for meaningful and valued active involvement and participation of consumers with the Agency, Contractor and other organizations in the community system in the following areas: •Governance •Policy development •System assessment, planning and evaluation •Contracting and procurement •Quality assurance, improvement and management. j. Provide Recipient Rights assistance in filing, reporting and referring alleged, suspected and apparent violations to the Agency’s Office of Recipient Rights; k. Provide organizational oversight, performance measurement and, monitoring of Customer Service functions at all applicable delegated levels; l. Provide monthly performance monitoring, tracking and reporting to the Agency’s CSO; m. Ensure consumers are provided with an Agency approved orientation that addresses: services, benefits and rights of the enrollee at time of enrollment; the enrollee will be informed of their rights annually, thereafter; n. Provide documentation, monitoring and reporting on Consumer Orientations to the Agency’s CSO; o. Ensure that consumers participate in the Agency’s efforts to assess consumer satisfaction with the system and services provided; and to protect those consumers from any harassment and /or retaliation that may result from participation. p. Provide information and assistance to consumers filing grievances, appeals and/or rights violations. 88 Sanctions A. In the event of a violation of any prevailing laws, regulations, and/or breach of contractual provisions regarding Customer Services by a MCPN, DCP, and /or CA, the Agency shall take immediate corrective action and will continue to monitor. Such violations of Customer Service may include, but not be limited to, the following: Any impediment to consumer’s access to the grievance and appeals procedures; Any impediment to monitoring by staff employed by the Agency; or Any harassment of, or retaliation against, any individual seeking to report, pursue a grievance or appeal or failure to cooperate with the resolution of a grievance or appeal. B. The MCPN shall take, or require prompt action against its Contracted Providers in the event of any violation of the aforementioned provisions. The MCPN and its Contracted Providers shall impose sanctions appropriate to the severity of the findings. Such actions may include, but are not limited to the following: Require removal of a staff from a service site or stop further referrals to the Contracted Provider; Remove the offending Contracted Provider from its network; Withhold all or a portion of contractual payments to offending Contracted Provider; Assess monetary sanctions reflecting the severity of the violation; and/or Terminate the Agreement. Michigan Department of Community Health Customer Service Standards The Michigan Department of Community Health (MDCH) mandates Customer Service standards. These standards are applicable to MCPNs, their subcontractors, CAs and direct contracted providers. Preamble: It is the function of the customer services unit to be the front door of the pre-paid inpatient health plan (PIHP), and to convey an atmosphere that is welcoming, helpful and informative. These standards apply to the PIHP and to any entity to which the PIHP has delegated the customer services function, including affiliate CMHSP(s), substance abuse coordinating agency (CA), or provider network. Functions: Welcome and orient individuals to services and benefits available, and the provider network. Provide information about how to access mental health, primary health, and other community services. 89 Provide information about how to access the various rights processes. Help individuals with problems and inquiries regarding benefits. Assist people with and oversee local complaint and grievance processes. Track and report patterns of problem areas for the organization. Standards: There shall be a designated unit called “Customer Services.” There shall be a minimum of one FTE (full time equivalent) dedicated to customer services. If the function is delegated, affiliate CMHSPs, substance abuse coordinating agencies and network providers, as applicable, shall have additional FTEs (or fractions thereof) as appropriate to sufficiently meet the needs of the people in the service area. There shall be a designated toll-free customer services telephone line and access to a TTY number. The numbers shall be displayed in agency brochures and public information material. Telephone calls to the customer services unit shall be answered by a live voice during business hours. Telephone menus are not acceptable. A variety of alternatives may be employed to triage high volumes of calls as long as there is response to each call within one business day. The hours of customer service unit operations and the process for accessing information from customer services outside those hours shall be publicized. The customer handbook shall contain all state-specified requirements. Note: The Agency’s CSO publishes this document and makes available to Direct Contractors, Managers of Comprehensive Provider Network (MCPN), their subcontractors and Substance Abuse Coordinators and their subcontractors. Customer services unit shall maintain current listings of all providers, both organizations and practitioners, with whom the PIHP has contracts, the services they provide, languages they speak, and any specialty for which they are known. This list must include independent PCP facilitators. Beneficiaries shall be given this list initially and be informed annually of its availability. Note: The Agency’s CSO publishes this document and makes it available to the intended beneficiary at the time of enrollment via the “Welcome Package.” Customer services unit shall have access to information about the PIHP including CMHSP affiliate annual report, current organizational chart, CMHSP board member list, meeting schedule and minutes that are available to be provided in a timely manner to an individual upon request. Upon request, the customer services unit shall assist beneficiaries with the grievance and appeals, and local dispute resolution processes, and coordinate as appropriate with Fair Hearing Officers and the local Office of Recipient Rights. Customer services staff shall be trained to welcome people to the public mental health system and to possess current working knowledge, or know where in the organization detailed information can be obtained in at least the following: 90 o o o o o o o o o o o o o *The populations served (SED, SMI, DD and SUD) and eligibility criteria for various benefits plans (e.g., Medicaid, Adult Benefit Waiver, MIChild), *Service array (including substance abuse treatment services), medical necessity requirements, and eligibility for and referral to specialty services, *Person-centered planning, Self-determination, Recovery & Resiliency, Peer Specialists, *Grievance and appeals, Fair Hearings, local dispute resolution processes, and Recipient Rights, Limited English Proficiency and cultural competency, Information and referral about Medicaid-covered services within the PIHP as well as outside to Medicaid Health Plans, Fee-for-Services practitioners, and Department of Human Services, The organization of the Public Mental Health System, Balanced Budget Act relative to the customer services functions and beneficiary rights and protections, Community resources (e.g., advocacy organizations, housing options, schools, public health agencies), and Public Health Code (for substance abuse treatment recipients if not delegated to the substance abuse coordinating agency). *Must have a working knowledge of these areas, as required by the BBA. Customer Service Staff Training All Customer Service staff hired at the Agency, Access Center, MCPNs, subcontractors, and CAs shall be trained on Customer Service within thirty (30) days of hiring and annually thereafter. Training is to be conducted by Agency approved trainers utilizing Agency approved training materials. In addition, Customer Service staff shall be expected to attend continuous staff training and education workshops and or seminars as directed by the Agency. Training shall be inclusive of topics that have been outlined in the Customer Service standards. It is the responsibility of the Agency, Access Center, MCPNs, subcontractors, and CAs to record, monitor, track and report on all Customer Service training and staff attendance to the Agency on a monthly basis. Information is to be submitted on the monthly D-WCCMHA Customer Service MCPN Monthly Activity Performance Tracking Report by the 5th day of the month. Customer Service Compliance Monitoring To insure that Customer Service functions are being carried out in accordance with Agency, Federal and State requirements, the Agency‘s Customer Service Office (CSO) is responsible for monitoring the MCPN’s compliance on an ongoing basis. This compliance monitoring includes reviewing monthly performance reports, and conducting periodic meetings with Direct Contractors, Managers of Comprehensive Provider Network (MCPN), their subcontractors and Substance Abuse Coordinators and their subcontractors to address compliance issues. An annual site assessment is also 91 conducted by the Agency’s Customer Service Office to address compliance standards as indicated by the following: The DWCCMHA/MDCH contract, The Access Center, Direct Contract Providers, Managers of Comprehensive Provider Network (MCPN), their subcontractors and Substance Abuse Coordinators and their subcontractors contract with the Agency, The Mental Health Code, Balance Budget Act (BBA), Americans with Disability Act (ADA), MDCH Customer Service Standards, Agency policies: o Customer Service o Grievance Process/Appeals o Intended Beneficiary Orientation o Accommodation o Recipient Rights o Limited English Proficiency (LEP) o Cultural Competency When conducting the site assessment, a monitoring tool is used that clearly identifies the specific standard that is being reviewed including the elements, criteria evidence that will be requested to meet the standard. The following are examples of key standards dictated by MDCH that are applicable to the customer service function and the specific elements that require evidence of compliance: Customer Service Standard Evidence of: Customer Service Identifiable functions Access to Services Performance Standards of Excellence and Efficiency Cultural Sensitivity and Accommodations Delegation of Customer Service Function A Welcoming Environment Grievances Standard Evidence of: Method for Filing Process for Handling Grievances Recordkeeping Delegation 92 Enrollee Rights Standard Evidence of: Intended Beneficiary Policy Right to Request and Obtain Information Right to be Treated with Dignity and Respect Right to Receive Information on Treatment Options Customer Service Performance Measurement The Agency’s Office of Customer Service is committed to providing leadership and support for the development of effective performance measures that support the mission, goals and values of the Agency as it pertains to customer service functions. DWCCMHA Access Center, Managers of Comprehensive Network (MCPN), their subcontractors, the Coordinating Agencie sand their subcontractors, and Direct Contracted Providers are expected to monitor, track and report customer service related performance measurements that are required by the Agency. Examples of performance measurements are as follows: Percentage of grievances resolved within sixty (60) calendar days. Percentage of consumers who receive an orientation within fourteen (14) business days after enrollment. Percentage of new Customer Service staff hired receiving a Customer Service orientation within thirty (30) days of hire. Percentage of Customer Service inquiries processed within twenty-four (24) hours. Dictated performance measurements are to be accurately tracked, recorded and reported to the Agency on the Monthly Performance Measurement and Tracking Report. If the Customer Service function is delegated to its provider network it is the responsibility of the MCPN to obtain this information and report to the Agency‘s CSO. It is expected that the following process will be implemented to accomplish the aforementioned: Direct Contractors, MCPNs, CAs, and their subcontractors must assign a unit or department at the MCPN who will be responsible for Customer Service performance measurements. Direct Contractors, MCPNs, CAs, and their subcontractors must develop an internal monitoring tool and system to address customer service activities, training, grievances, enrollment and orientation processes within its provider network. Direct Contractors, MCPNs, CAs, and their subcontractors must develop a system that will tabulate, document, and provide timelines to report their information. 93 Direct Contractors, MCPNs, CAs, and their subcontractors must insure that at each of the service provider sites there is a staff or unit who will be responsible for gathering, reporting, and sending the tracking information for timely submission to the Agency's Customer Service Office. The areas that are to be tracked monthly and monitored are: - Number of Customer Service calls handled Number of Customer Service calls resolved within 24 hours Number of Customer Service Walk-ins Number of Grievances handled Number of Grievances that exceeded a 60-day resolution The tracking of continued education training of Customer Service staff Customer Service Satisfaction Surveys. Consumer education and training attendance Supports and Accommodations provided to Consumers that are enrolled in the Enhanced Consumer Employment program. Other activities as dictated by the MCPN The MCPN is required to report their Customer Service monthly activity to the Agency’s Customer Service Office by the 5th of each month utilizing the D-WCCMHA Customer Service MCPN Monthly Activity Performance Tracking Report Form. Limited English Proficiency (LEP) The Agency MCPNs and affiliates, and Direct Contractors must take reasonable steps to provide Consumers with Limited English Proficiency with meaningful access and opportunity to participate in Agency-funded programs by doing the following: Develop policies and procedures that will assure language assistance to Consumers with limited English proficiency Ensure all services, programs, or activities shall be available to Consumers with LEP. Provide adequate information to enable Consumers with LEP to understand the types of services and benefits available. A balance must ensure meaningful access by Consumers with LEP to critical services while not imposing undue burdens on the entity. Applying the four factor analysis might lead to the conclusion that different language assistance measures are sufficient for different programs or activities. An individualized assessment that: balances the following four factors should be conducted: 1. The number or proportion of LEP Consumers eligible to be served or likely to be encountered. (This may be obtained through an examination of the latest census data for the area served data from school systems and community organizations.) The greater number or proportion, the more likely language services. 94 2. 3. 4. 5. The frequency with which LEP individuals come in contact with the program. The more frequent the contact with a particular language group, the more likely that enhanced language services are needed. (e.g. a program that encounters LEP Consumers on a daily basis most likely may have a greater obligation than a program that encounters LEP Consumers sporadically.) The nature, importance, and urgency of the program. The more essential and crucial the activity, it is more likely that language services are needed. (e.g. the communication of rights to a person whose benefits are being terminated.) The resources available to provide effective language assistance. Reasonable steps may cease to be “reasonable” where costs imposed substantially exceed the benefits. Provide a range of language assistance which may include: Use sign language interpreters for individuals with hearing impairments/limitations. Disseminate alternative formats such as large print or Braille for individuals with visual impairments/limitations. Provide bilingual employees that are trained and competent in interpreting. Test identified bilingual staff to assure language proficiency. Contract with outside interpreter(s) to meet the language needs of Consumers served. Formally arrange for the services of trained and skilled voluntary community interpreter(s), which includes for testing of a level of fluency. Provide telephonic language interpreter service as needed. This may be used as a supplemental system or when other resources cannot accommodate a language encountered. Ensure that interpreters are familiar with terminology used in to the provision of mental health and substance abuse services. Ensure that vital documents are available in language(s) other than English of each regularly encountered LEP group eligible to be served or likely to be affected by the program. Ensure access by, at a minimum, providing notices in writing, in the LEP individual’s primary language, of the right to receive free language assistance in language other than English, including the right to competent oral translation of written materials free of cost. Notice can be provided by, but not limited to: 1. 2. Use of language identification cards, which allow LEP beneficiaries to identify their language needs. A message on the card must invite the LEP person to identify the language he/she speaks. Identification must be included in the individual’s record. Posting signs in regularly encountered languages (in accordance with Federal safe harbor guidelines) other than English in waiting rooms, reception areas, and other initial points of entry. These signs must inform applicants and beneficiaries of their right to free 95 3. 4. 5. language assistance services and invite them to identify themselves as Consumers needing services Translation of applications and instructional, information, and other written materials into appropriate non-English languages by competent translators. Uniform procedures for timely and effective communication between staff and LEP individuals. This includes instructions for English speaking employees to obtain assistance from interpreters or bilingual staff when receiving calls from, or initiating calls to LEP individuals. Inclusion of statements about services available and the right to free language assistance services, in applicable non-English languages in brochures, booklets, outreach and recruitment information and other materials routinely disseminated to the public. Disseminate Limited English Proficiency policy to staff. (i.e., through staff training, initial orientation, memoranda, etc.) Provide training to new employees and annually thereafter (or as new or existing regulations modify standards of business/clinical practice to ensure all professionals are: 1. 2. 3. Knowledgeable and aware of LEP policy and procedures. Are trained to work effectively with interpreters. Understand the dynamics of interpretation between consumers and the interpreter. Monitor its language assistance program periodically to assess: 1. 2. 3. 4. 5. 6. The current LEP makeup of its service area. The current communication needs of LEP applicants and consumers. Whether existing assistance is meeting the needs of such Consumers. Whether staff is knowledgeable about policies and methods of implementation. Whether sources of arrangements for assistance are still current and viable. If modifications are needed. Intended Beneficiary/New Enrollee Orientations State and Federal requirements dictate that intended beneficiaries (Consumers) are to be provided a timely orientation to the benefits and services available, including how to access them within the Agency, MCPNs, CAs, and their subcontractors. The MCPN/CA is responsible for orientating Consumers via the Intended Beneficiary (Consumer/Enrollee) Orientation Process as required by the State of Michigan. These services must be provided within the Michigan Department of Community Mental Health/Community Mental Health Provider Managed Specialty Supports and Services 96 Contract, Section 4.7.1, Customer Services, and Section 3.12, Compliance with Civil Rights and Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d ET. Seq. The Agency’s Customer Service Unit is responsible for ensuring that Customer Service divisions of the MCPNs and contracted service providers and their entities, the Access Center and Coordinating Agencies comply with the following orientation procedure: Shortly after initial enrollment and or at the time of initial intake, all intended beneficiaries are to be made aware of their need for an orientation to mental health service, benefits and how to access them within 3 – 7 business days. The intended beneficiary shall receive an orientation packet which includes information on the following: o o o o o o o Welcome letter to Detroit – Wayne County Community Mental Health Agency and MCPNs Handbook Recipient Rights Handbook Consumer Handbook (supplied to the MCPN by the Agency) Grievance and Appeals Pamphlet Customer Service Related Brochures Information from MCPN and Service Providers (i.e. information specific to their organization) Advance Directive Brochure The intended beneficiary must be provided detailed information specific to each MCPN regarding: o o o o o o o o o Benefits covered; Cost sharing, if any; Service area (i.e., Wayne County); Names, locations, telephone numbers of current affiliated providers with ability to communicate with non-English language Consumers; Information about where and how to obtain counseling or referral services that are not covered because of moral or religious objections; The notification to all Consumers and potential beneficiaries of the availability of information in alternative formats, taking into consideration their special needs (e.g., visual, limited reading proficiency), and how to access those formats; A mechanism to help Consumers and potential beneficiaries understand the managed care program, and the requirements and benefits of the plan; The availability of written information in the prevalent non-English languages in Wayne County in accordance with the Federal Limited English Proficiency Guidelines and/or the Agency’s contract with the Michigan Department of Community Health (MDCH); and The availability, free of charge, of oral interpretation services to nonEnglish languages (not just those identified as prevalent) in accordance with State and Federal guidelines. General information must be furnished to the beneficiary/person as follows: 97 Notification at least annually, of the right to terminate their relationship with their MCPN and the right to change MCPNs; Notification of any restrictions on the freedom of choice among network providers; Notification of rights and protections (as noted in subsection E, below); o o o Notification of free exercise of rights: the beneficiary/person is free to exercise his or her rights, and that the exercise of those rights will not adversely affect the way the Agency, MCPN, or its providers, or the Michigan Department of Community Health (MDCH) treat the beneficiary/person. Notifications of their right to a “Psychiatric Advance Directives.” Information on the structure of the Agency or the MCPN/CA, and the scope and process of accessing emergency services and postemergency care including: Prior authorization is not required for emergency services. The process and procedures for obtaining emergency services, including the proper use of the local 911-telephone system. The locations of any emergency services at which providers and hospitals furnish emergency services and post-stabilization services covered under the Agency/MCPN Contract. The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that beneficiaries/Consumers understand the benefits to which they are entitled. Procedures for obtaining benefits, including authorization requirements Identified Customer Service Staff shall conduct the orientation by reviewing each document in the orientation packet and highlighting the entitled benefits, services and process on how to access them. The Intended Beneficiary is to be provided an opportunity to ask questions. Upon completion of this process the Intended Beneficiary is to be given the applicable customer service phone numbers and advised where to call for questions. The New Enrollee shall be informed of the Agency and MCPN/CA service structure. Consumers must be informed of the following Enrollee Rights: These rights shall include but are not limited to the following: Recipients have a right to: a list indicating where non-English languages regarding mental health services are spoken and by whom, within the provider network. Recipients have the right to: the rules that govern grievances, appeals, and fair hearings, along with information regarding representation at hearings, hearing requirements, time frames and the toll free number; and/ or information regarding continuation of benefits during the process of the hearing, if requested. Recipients have the right to: request the process by which benefits from out-ofnetwork providers are obtained. 98 Recipients have a right to: information about emergency and post-stabilization services (outpatient services received during follow-up after an episode of inpatient care), and to be informed that prior authorization is not required to receive emergency services from any inpatient facility. Recipients have a right to: request information on advance directives. All adult recipients must be provided written information regarding advance directives including, any State laws that apply to advance directives. Recipients have the right to: request additional information, including information regarding the structure and the operation of Agency, MCPNs, Carve- Out Contractors, and Coordinating Agencies (CAs); and whether these individual agencies use physician incentive plans. The Agency/ MCPN/Affiliate/Carve- Out Contractors, CAs is responsible for providing this information upon request. Recipients have the right to: request informational materials regarding their rights as recipients of mental health services and to be notified annually of their right to obtain information materials. The Intended Beneficiary is expected to sign the Intended Beneficiary Orientation Log Sheet and the Detroit-Wayne County Community Mental Health Agency (D-WCCMHA) New Intended Beneficiary Orientation Receipt Form. Upon completion of the Orientation, the Intended Beneficiary is provided an Orientation Evaluation form to complete. Copies of the New Intended Beneficiary Orientation Log Sheets are to be tallied monthly and reported to the MCPN Customer Service Unit They will then be expected to prepare a final orientation tally Report and forwarding monthly to the Agency’s Customer Service Unit. Note: Upon request, original Orientation log sheets are to be made available for Agency Site Reviews. Copies of the signed D-WCCMHA New Intended Beneficiary Orientation Receipt Form are to be immediately filed in the Intended Beneficiary’s Medical Record File and made available upon request, for Agency site review purposes. Orientation presentations and materials when applicable, must be modified to accommodate the special needs of the Intended Beneficiary i.e. Consumers with physical disabilities, hearing and/or visual impairments, limited English proficiency, and alternate forms of communication. Grievance Process It is the policy of the Agency to follow all regulatory requirements regarding the grievance and appeal processes. The Agency’s Customer Service Office, MCPN/CAs, Direct Contractors and Subcontractors are responsible for facilitating the grievance process. This process involves the following: 99 The primary goal of the grievance process is to promote a resolution of recipients’ concerns or complaints. All recipients have the legal right to a fair and efficient process for resolving complaints regarding their services and supports delivered by the Managers of Comprehensive Provider Networks (MCPNs),Coordinating Agencies (CAs) and Direct Contractors. The policy also provides consumers with options that are timely, objective, fair, accessible and understandable. The concerns/complaints from recipients can be submitted orally or in writing. The Customer Service Units must provide assistance in securing, completing and forwarding forms or paperwork related to filing a grievance. Provided interpreter services and toll-free numbers that have adequate TTY/TDD and interpreter capability. Ensure that consumers are informed of their grievance process rights as it relates to their Medicaid (Medicaid Fair Hearing) or Non-Medicaid (Alternative Dispute Resolution) status. o Expediting an appeal when it is determined that following the standard timeframe could seriously jeopardize the beneficiary’s life or health or ability to attain, maintain, or regain maximum function. o Medicaid beneficiaries have the right to have a provider, acting on the beneficiary’s behalf and with the beneficiary’s written consent, file an appeal to the PIHP/MCO. The provider may file a grievance or request for a State fair hearing on behalf of the beneficiary only if the State permits the provider to act as the beneficiary’s authorized representative in doing so. Customer Service Units must maintain records of grievances and their resolutions. Records must be available for review and copies of all forms and letters mailed to recipients. Monthly logs of all grievances are maintained in MH-WIN. MCPN/CAs and Direct Contractors are required to submit quarterly and annual reports that analyze the grievance data for trending and tracking patterns. The quarterly and annual reports are reviewed by the Agency’s Quality Management for performance monitoring. Informal Grievances Grievances initiated at the MCPN/CA, Direct Contractor, and Subcontractors’ level for resolution are referred to as Informal Grievances. This process shall include the following: 100 MCPN/CAs, Direct Contractors and Subcontractors shall process and facilitate resolution of informal grievances. MCPN/CAs, Direct Contractors and Subcontractors shall ensure the informal grievance is initiated at the time a consumer is expressing dissatisfaction with services. Appropriate staff, who is not the subject of the grievance, is responsible for addressing and or resolving the Consumer’s concerns. Professionals with the appropriate clinical expertise must be consulted for all informal grievances that involve clinical issues. Customer Service shall ensure that all informal grievances are processed timely by completing documentation in MH-WIN. MCPN/CAs, Direct Contractors and Subcontractors all have the responsibility to: Complete and forward an Acknowledgement letter to the consumer, parent or Legal Representative within five (5) business days of receipt of their grievance. Complete and forward a Status letter to the consumer, parent or Legal Representative by the 30th day for grievances pending resolution beyond (30) calendar days. Discuss grievance resolution with the consumer, parent or legal representative. Complete and forward a Letter of Resolution within sixty (60) calendar days. All grievances are to be documented in MH-WIN and must be reviewed by the MCPN/CAs, Direct Contractors, and Subcontractors’ Grievance Coordinators to ensure compliance with the mandated guidelines. Monthly logs of all grievances are maintained within MH-WIN. All quarterly and annual narrative reports must summarize trends and tracking patterns. The reports are to be submitted quarterly and annually to the Agency CSGC by the following dates: 1st Quarter – Due January 15th 2nd Quarter – Due April 15th 3rd Quarter – Due July 15th 4th Quarter – Due October 15th Annual-Due December 15th Formal Grievances Grievances that are initiated at the level of the Agency for resolution are referred to as Formal Grievances. This process shall include the following: Consumers, parents and/or Legal Representatives may contact the Agency’s Customer Service Office to file a formal grievance by calling, writing or visiting the Customer Service Office. The Agency’s Customer Service Office may be reached at 1-888-490-9698 and/or TDD line 1-800-630-1044 between the hours of 8:00 a.m. and 4:30 p.m. Monday through Friday. 101 Walk-in formal grievances may be facilitated at the Customer Service Office located at 640 Temple, 2nd floor, Detroit, MI, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday. Written formal grievances may be submitted in writing to: Detroit-Wayne County Community Mental Health Agency Customer Service Office 640 Temple, 2nd Floor Detroit, MI 48201 The Agency‘s Customer Service Office shall ensure that a professional with the appropriate clinical expertise is consulted on all grievances that involve clinical issues. The Agency’s Customer Service Office shall ensure that all formal grievances are processed timely by: o Completing all documentation of grievances in MH-WIN. Completing and forwarding an Acknowledgement letter to the consumer, parent or Legal Representative within (5) business days of receipt of their grievance. Completing and forwarding a Status letter to the consumer, parent or Legal Representative by the 30th day for grievances pending resolution beyond (30) calendar days. Completing and forwarding a Letter of Resolution within (60) calendar days. Inform consumers, parents and Legal Representatives of appeal options. State Fair Hearing Process A complainant may have access to the Medicaid Fair Hearing Process when an entity responsible for resolving the grievance, fails to respond to the grievance within sixty (60) calendar days. This constitutes an “action” and can be appealed to the Michigan Department of Community Health Administrative Tribunal for a Medicaid Fair Hearing. Federal regulations provide a Medicaid beneficiary the right to an impartial review (fair hearing) by a state level administrative law judge, of a decision (action) made by the local agency or its agent. A Medicaid beneficiary has the right to request a fair hearing when the PIHP or MCPN/Service Provider takes an “action” or a grievance request is not acted upon within sixty (60) calendar days. Beneficiaries are given ninety (90) calendar days from the date of the 60-day failure to act upon a grievance request to file for a fair hearing. State Fair Hearing requests must be written. The beneficiary, or representative, may file a complaint using either a Request for Fair Hearing form or on any paper. Request for Fair Hearing forms are available at the MCPN/Affiliate, Direct Contract Service Provider or by contacting: Detroit-Wayne County Customer Service Office 640 Temple – 2nd Floor Community Mental Health Agency 102 Detroit, Michigan 48201-2558 Phone: (888) 490-9698 or (313) 833-3232 TDD: (800) 630-1044 Written State Fair Hearing requests should be forwarded to the following address: Michigan Administrative Hearing System P O Box 30763 Lansing, Michigan 48909-7695 Consumer Affairs The Agency’s CSO is responsible for assisting the Agency in advancing and championing intended beneficiaries command of the community system in ways which supports recovery and self determination by coordinating programs and activities that involve consumer outreach and participation. This is accomplished through various forums including: – Monthly Consumer Meetings that are held at the Agency and cover topics on Recovery, Self Determination, Peer Support, Skill-building etc. – Partnership Initiative Meetings which meets monthly as a focus group of Consumers who address Agency concerns, plan the upcoming Monthly Consumer Meeting and edit the Agency “What’s Coming Up!” calendar. – Consumer Newsletters- “Person Points of View” which is published quarterly. The newsletter committee is comprised of primary Consumers who write articles and report on current Agency events. – Peer Support Specialist Meetings which meet bi-monthly to provide a forum for Wayne County-trained Peer Support Specialists to meet, network and receive continuing educational training offered by the Agency. – Clubhouse and Drop-in Center meetings to survey areas of concerns and promote educational opportunities and inclusion in Agency initiatives. – Community Projects the Agency routinely participates in i.e. Health Fairs, Town Hall Meetings, educational forums and engagements. – Consumer Resource Center offers a place where Consumers can meet to use various educational materials and communications equipment. The Center can accommodate small groups for conducting business meetings. Consumer Family Advocate Council (CFAC) is an administrative advisory arm to the Agency’s Executive Director. CFAC is charged with voicing concerns of consumers, family members, and advocates regarding mental health related issues, i.e. specifically as they relate to people with developmental disabilities, mental illness and substance use. CFAC also promotes the inclusion of Consumer, family members and advocates in the design process of mental health services, education and outreach at – 103 events including Annual Consumer Conference, “We Are Family” Picnic and promotions of educational seminars and literature. CFAC meets monthly at the Agency the 3rd Friday of each month at 12:00pm. CFAC’s activities are coordinated via the Agency’s Office of Customer Services. The Agency encourages the MCPN, CAs, Direct Providers, and their subcontractors to collaborate with the Agency’s Office of Customer Service in promoting Agency and network Consumer outreach. Supported Consumer Employment The Agency’s Office of Customer Service, Consumer Affairs Unit is responsible for the coordination and facilitation of D-WCCMHACMHA Consumer Supported Employment Program. The program which is referred to as the Enhanced Consumer Employment Program originated in 2002 as a result of the State AFP Consumer employment requirement. The program offers a venue for: – Consumers to meet their person-centered planning process for the obtainment of employment. – To focus on skill building, training, counseling and continuous monitoring of the Consumer's supports and accommodation needs. – To groom individuals to become capable of moving into a competitive employment position with full benefits. The program encourages job placement of D-WCCCMH Agency Consumer’s in the MCPN and service provider network. MCPNs and service providers may obtain information on placement by contacting the Customer Service Office at 313- 888-4909698 or 313-3232. 104 Recipient Rights 105 Recipient Rights The ORR Mission Statement To ensure that recipients of mental health services through the Detroit-Wayne County Community Mental Health Agency receive individualized treatment services suited to his/her condition as identified in their individualized plan of service, that is developed in the Person Centered Planning process, and receives services in a safe, sanitary, and humane environment where they are treated with dignity and respect, free from abuse and neglect. Overview of the Office of Recipient Rights The Office of Recipient Rights (ORR) is a unit of the Detroit-Wayne County Community Mental Health Agency (D-WCCMHA). ORR takes actions that are appropriate and necessary to safeguard and protect the Rights guaranteed to recipients receiving services through the D-WCCMHA and the contracted service provider network as mandated by the Federal statutes, Michigan Mental Health Code (MHC), Administrative Rules, MDCH Contract and D-WCCMHA policies. The ORR protects the rights of recipients receiving services by: Complaint resolution through the investigation of allegations of Recipient Rights violations that are within the Agency’s jurisdiction. Providing Recipient Rights training for all employees, volunteers and agents within the Wayne County Public Mental Health System. Monitoring of each service site under contract within the service delivery network at least annually for compliance with the Recipient Rights mandates of the MHC, DWCCMHA policies, the Individualized Plan of Service (IPOS) and other established laws and standards of care. Providing advocacy and support to the recipients of treatment Contractor and Subcontractor Responsibilities As an identifiable management function, the Executive Director of organizations under contract with the D-WCCMHA, either directly or indirectly, shall ensure that the organization is responsible for the performance of functions related to recipient rights and that staff is adequately trained and qualified to perform these functions. Ensure ORR unimpeded access; to all programs and services operated by or under contract with D-WCCMHA; all staff, volunteers and agents employed by or under contract with D-WCCMHA, and all evidence necessary to conduct a thorough investigation Applicants for, and recipients of mental health services or their guardians, and in the case of minors, the applicant's or recipient's parent or guardian, shall be notified by the providers of those services of the rights guaranteed by MHC. Notice shall be accomplished by providing an accurate summary of chapter 7 and chapter 7a to the applicant or recipient at the time services are first requested and by having a complete copy of chapter 7 and chapter 7a readily available for review by applicants, recipients and guardians. Directly providing or ensuring that consumers are informed of their rights, including being provided a copy of the Recipient Rights Handbook. 106 Provide notification of Recipient Rights, Confidentiality, Person Centered Planning at the initiation of services and at least annually thereafter. Ensure current and approved ORR contract language is included in all contracts for service. Be available to respond to consumers and staff who have questions regarding Recipient Rights. This includes referring consumers (or making the contact on behalf of the consumers) to the ORR, and conducting the necessary follow-through to ensure consumer access to the rights protection system. Remedial action Ensure timely response and appropriate remedial actions if it has been determined through investigation that a right has been violated. The remedial actions must meet all of the following requirements: Corrects or provides a remedy for the rights violations. Is implemented in a timely manner. Attempts to prevent a recurrence of the rights violation. Substantiated reports of abuse, neglect, retaliation or harassment, REQUIRE disciplinary action for the employee, volunteer, or agent of a provider. Appropriate disciplinary actions are; Written Counseling Written Reprimand Demotion Suspension Reassignment Termination The action shall be documented and made part of the record maintained by the ORR. No Retaliation. The Contracted Provider shall not retaliate in any manner against its employees, independent contractors, the Agency's Recipient Rights staff, consumers, or any other Recipients for any actions pertaining to the notification, reporting, filing of required written reports, the investigation of, or the cooperation in an investigation of alleged or suspected Recipient Rights violations. The entitity shall ensure Recipient Rights staff are protected from pressures that could interfere with the impartial, even-handed, and thorough performance of their duties, and shall take appropriate disciplinary action against Contractors if there is evidence of harassment or retaliation. Sanctions Where contractors have failed to take appropriate corrective or remedial action, the contracting entity shall take immediate remedial action in the event of breach of the Mental Health Code or of the contractual provisions regarding Recipient Rights, including but not limited to, the following: (i) any impediment to consumer’s access to the complaint and appeals procedures, (ii) any impediment to monitoring or investigation by rights officers employed by the Agency, or any harassment of, or retaliation against, any individual seeking to report, pursue or investigate a rights violation or failure to cooperate with an investigation of a rights violation. The contracting entity shall take or require prompt action against its Provider or its Contractors in the event of any violation of the Code or these provisions. The contractor and its contracted provider shall impose sanctions for substantiated 107 complaints appropriate to the severity of the findings. Such actions may include, but are not limited to: a) Require removal of a recipient from a service site or stop further referrals to the Contracted Provider; b) Remove the offending Contractor from its network; c) Withhold all or a portion of contractual payments to offending Contractor; d) Assess monetary sanctions reflecting the severity of the violation; e) Terminate the Agreement. Monitoring ORR and certified volunteer monitors of the ORR shall have unimpeded access to; all programs and services operated by or under contract with D-WCCMHA; all staff employed by or under contract with D-WCCMHA, and all evidence necessary to fulfill its monitoring function. Contractor is expected to ensure timely and appropriate responses to all corrective actions required by D-WCCMHA as a result of announced or unannounced site review visit. Contractor is expected to monitor all sites of service within the scope of its contract to ensure a uniformly high standard of rights protection throughout its service delivery system in accordance with Federal, State and local laws, DWCCMHA policies. Contractor shall monitor each site of service to ensure o that recipients, parents of minor recipients, and guardians or other legal representatives have access to summaries of rights guaranteed by the Mental Health Code (Blue Book) and are notified of those rights in an understandable manner, both at the time services are requested and periodically during the time services are provided to the recipient. o Telephone number and address of the Office of Recipient Rights are conspicuously posted o YOUR RIGHTS booklet (Blue Book) o Recipient Rights complaint forms o Other postings as required Employee Training Ensure that all staff, volunteers and agents of the entity has completed recipient rights face-to-face new hire training within 30 days of hire and completed recipient rights update training annually thereafter. Participate in training events and meetings sponsored by the ORR to become better informed regarding recipient rights related issues and developments as well as efforts of continued learning. Reporting Requirements Report all incidents of abuse and neglect (and safeguarding) in accordance with Federal, State, local laws, MDCH Requirements for reporting abuse and neglect and D-WCCMHA policies, guidelines and contractual agreements. Additionally, any staff, volunteer or agent of the contractor who has reasonable cause to suspect the criminal abuse of a recipient immediately shall make or cause to be made, by telephone or otherwise, an oral report of the suspected criminal abuse to the law enforcement agency for the county or city in which the criminal abuse is suspected 108 to have occurred or to the state police, Adult Protective Services and if applicable, Bureau of Child and Adult Licensing. Death reporting The contractor shall report the death of a consumer to the Office of Recipient Rights within 24 hours of the provider being notified of the death. Incident Reporting Contractors and subcontractors shall report within 24 hours any and all unusual occurrences involving individuals receiving contracted mental health services. All incidents shall be reviewed to ensure that the rights of all parties involved are protected. All incidents shall be reviewed to assure that sufficient corrective action has been provided to remediate the situation and prevent reoccurrence. Behavior Treatment Committees Ensure inclusion of Recipient Rights staff as ex-officio members in all Behavior Treatment Committees Quality Improvement A written protocol to address the use of recipient rights data and information as part of the planned quality improvement efforts. 109 Communication 110 Communication Sharing Information with Consumers MCPN and Direct Contracted Providers (DCP) Board of Trustees (or comparable governing body) and Board Committee meetings related to its performance of the contractual agreement with the Agency must be open to the public. The MCPN and the DCP must provide reasonable advance notice for such meetings and allow for input from consumers, advocates and citizens. Additionally, the MCPN and DCP must ensure, through its contracts with providers and provider monitoring, that the subcontractors adhere to similar requirements. The only exceptions to open meeting requirements recognized by the Agency are those meetings that are solely dedicated to attorney-client privileged information and/or confidential patient information. Sharing Information with Subcontractors and Line Staff The MCPNs and DCPs are expected to communicate and train individuals as necessary on applicable policies, procedures, Medicaid regulations, Agency requirements/standards, and other relevant information that will assist the subcontractor and its staff in providing care and services to consumers. It is particularly important that line staff have all the information available to assist them in providing care. Marketing Standards Definition Material that is intended primarily to attract or appeal to eligible Consumers and to promote membership retention by providing general information about the Comprehensive Provider Networks (MCPN) and Direct Contracted Providers and the services offered. Materials include written information, letters developed for mass mailing, and any other communication that is directed to more than 25 individuals. Requirements All materials that may be distributed or used in advertisement or promotion to individuals or guardians/family members of individuals who are Developmentally Disabled, Seriously Emotionally Disturbed, and/or Seriously Mentally Ill must be reviewed and approved by the Agency 30 days prior to distribution of those documents. No materials may be distributed without approval of the Agency All submitted materials must be “camera ready”, i.e. ready for print or in final format before submitted to the Agency for review MCPNs are not be required to adhere to a specific format when developing communication materials Material readability must be at the 4th grade level 111 Materials must be translated to a language alternative when an alternative language-related population comprises 5% of the eligible population including, at a minimum, Spanish, Chinese, Arabic, French, Italian, and Polish Materials in non-English languages or Braille must be submitted in the non-English or Braille format, “camera ready” version accompanied by an English translation of the communication along with a letter of attestation from the CEO that both documents convey the same information A professional translator must translate materials. The name and the translator’s credentials must accompany any translated materials submitted to the Agency Materials must be printed in 12-point or larger font size, preferably in the New Times Roman type All marketing conveyances (e.g., newspaper, radio, TV, brochures, etc.) are applicable to the marketing requirements Marketing material must clearly explain the concept of networks and subnetworks and the concept of choice. Annual letters of notification for re-selection must disclose the names and telephone contact numbers for other MCPNs offered in the service area. The person’s ability to choose a new MCPN or transfer MCPNs must be clearly explained in all the marketing materials. Descriptions of the Quality of the MCPNs network and DCPs must not be “embellished”. For example: MCPNs and DCPs can not use: Superlatives (e.g., highest, best) Unsubstantiated comparisons with other MCPN networks or DCPs Direct negative statements about other MCPNs or DCPs including individual statements from members MCPNs and DCPs can use: Qualified superlatives (e.g., among the best, some of the highest) Superlatives (e.g., ranked number 1) if they can be substantiated by ratings, studies or statistics; the source must be identified in the advertisement Survey data regarding own organization (but may not use it to make specific comparison to others) Testimonials must comply with marketing material review guidelines and cannot use negative testimonials about other MCPNs, CAs, or DCPs. If the MCPN uses the name and/or picture of providers and/or facilities to market itself, the provider information may only be used within the context of informing potential Consumers with choice or current Consumers that the provider is associated with the MCPN’s network. The MCPN cannot imply that the provider is exclusively available through his/her network unless such a statement is true. 112 Marketing materials or efforts cannot discriminate Marketing staff cannot be solely compensated on commission It must be clear to the Consumer with choice who is selecting a MCPN that the MCPN holds a contract with D-WCCMHA. 113 Reporting Requirements 114 Reporting Requirements MCPNs, CAs and Direct Contract Providers are required to report: Quality Performance standards as outlined in the Contract and the Performance section of this manual. Recipients Rights data as outlined in the Contract and the Recipient Rights section of this manual. Financial performance as outlined in the Contract and the Finance section of this manual Recipient services via encounters in electronic or direct data entry format as indicated per contract. This includes Consumer Demographic data and the Peer Support codes. Utilization Data as outlined in the Management of Services section of the manual and the contract Monthly Financial Statement including a narrative outlining explanations for significant variances and % of paid claims outstanding Quarterly Narrative Report from the Direct Contractors Monthly Provider Network List – this list must include a column indicating that the provider is/is not accepting referrals E-form data- electronic or direct data entry submission of E-form data as indicated per contract. The Agency, CAs, MCPNs and Direct Contractors will work collaboratively to determine the remainder of the Agency’s reporting needs, timing and format. The Agency expects that periodically reporting needs will be examined, refined, and revised as data is collected and available. Additionally, the Agency anticipates that the States requirements will change. It is incumbent upon the MCPNs, Direct Contractors and their subcontractors to be capable of responding to new reporting requirements as they are presented. 115 Information Systems 116 Information Systems Overview The network manager’s Managed Care Information System (MCIS) should be designed for use in a Managed Care setting. It must accommodate, maintain and report data for Consumers receiving services, providers rendering behavioral health services, and payers managing and reimbursing providers for the delivery of medical services. It is critical that the MCIS accommodate a large number of the administrative tasks that take place between these three parties. The information system for the MCPN and Coordinating Agencies must include the following qualifications: Ability to import and manage enrollment information; Ability to store and report member specific socio-economic information; Ability to store and report other sources of benefit coverage (COB) information; Ability to store and accurately reflect the subcontractor’s structure for the MCPNs or CAs; Ability to capture, store, and report utilization data for all levels or care/services; Capability of adjudicating claims and encounters; Ability to store, manage and report member rights issues; Ability to support clinical and business analysis; Compliance with HIPAA standards as required by federal and state laws; and Ability to transfer and receive data between the Agency and the MCPN using ANSI Standard, HIPAA compliant transaction formats. The MCPN shall have and maintain a Management Information System and related practices that reflect sufficient capacity to fulfill the obligations as a contractor. Management information systems capabilities are necessary for at least the following areas: Monthly downloads of Medicaid eligible information; Person registration and demographic information; Provider enrollment; Third party liability activity; Claims payment system and tracking; Grievance tracking; Tracking and analyzing services and costs by population group, and special needs categories as specified by the MDCH; Encounter and demographic data reporting; Performance indicator reporting; HIPAA compliance; 837 submission; 117 UBP (Uniform Billing Project) compliance; and User access and satisfaction. MH-WIN MH-WIN is the Agency web-based MCIS application. Each MCPN must ensure that its subcontractors have access to MH-WIN so that eligibility lookup capability is always available. The Agency will ensure that the subcontractor obtains access to MH-WIN in a reasonable time frame (no greater than 7 business days) after receiving all necessary information from the MCPN. The MCPN subcontractor must have Internet access in order to use MH-WIN. This cost of internet access will not be incurred by the Agency. Encounters MCPNs must submit encounters directly to the Agency MH-WIN system weekly. Funding Funding will be delivered monthly to the network managers in the ANSI X12 820 format. Membership Lookups All MCPNs and subcontractors may review membership eligibility in MH-WIN. The MCPNs may request access to MH-WIN by completing the Agency’s MCPN Provider Data Sheet. See the Provider Data Sheet in the Forms section of the Manual 118 Finances 119 Finances Funding Sources The Agency receives the majority of its funding from the State of Michigan and Wayne County. It is expected that the MCPNs obtain funding from private and other available public sources (as provider’s have done in the past) as well as from the Agency. The Agency expects the MCPNs to seek and utilize funds from other sources whenever possible providing services. It is the intent that non-Agency financial resources be utilized as the first source of payment. Medicaid Spend-Down The MCPN must provide or must ensure that its subcontractors provide the MCPNs and the Agency with all appropriate documentation of the Person’s Medicaid spend down status on a monthly basis. The MCPN’s subcontractors must assist and support Consumers with this monthly process. MCPNs may refer to the State of Michigan spend down policies accessed through the state’s web site. Payment Schedule Electronic Fund Transfer will be made available on the 15th of the month in which services are rendered unless the 15th is not a business day in which case the payment will be available the preceding business day. Payment Cell Notification An enrollment tape will be provided monthly, approximately by the first of the new month and the assigned payment cell will be identified in that communication. Reconsideration Individual reconsideration of payment cell assignment will not be entertained unless an obvious clerical error is evident. Periodically, the entire population will be reanalyzed. Adjustments will be accomplished at the time of reanalysis. Flagged for outcome of discussion of consumers in appropriate rate bands Capitation Reconciliation The Agency will reconcile the per member per month (PMPM) payment calculation to the population attributed to a given network. Transfers in and out of the network from previous month’s enrollment will be checked to determine that the PMPM is reflective of the population being served. Any discrepancies the MCPN identifies will be forwarded to the, Finance Director at D-WCCMHA for immediate resolution. 120 Reporting The MPCN will file monthly Financial Statements prepared in accordance with GAAP and such supporting schedule as required by the Agency by the 10 th of the month following the month closed. These interim financial statements will be defined as a Statement of Financial Position, Statement of Activities and Statement of Cash Flows. Other statements may be identified and requested from time to time. A narrative shall be included to explanation significant variances and % of paid claims within 30 days. Annual Audited Financial Statements must be made available within 90 days of year end along with all supporting schedules as requested by the Agency. Annual Compliance Examination must be made available within 120 days of the year end. The Compliance Examination can be found on the State of Michigan’s website. Annual 990 tax return information must be made available within 105 days of year end and should include the MCPN and its top six providers. Annual community hospital payments must be made available within 105 days of year end. The information should include the per diem amount, Medicaid dual and non dual payments for the fiscal year. Billing The following types of authorized services will be paid by the MCPN. Acute Inpatient Psychiatric Hospitalizations – UB92 Partial Hospitalizations – UB92 Residential –1500 Intensive Crisis Residential – 1500 Child Placement – 1500 Supportive Independent Living – 1500 Electro Convulsive Therapy – UB92 Psychiatric Consults (Medical Surgical Patient) - 1500 State Hospital admissions will be billed to the Agency by the State Hospitals. The Agency will no longer withhold funds from each MCPNs PMPM to fund State Hospital utilization . The Agency will provide 4.5% for administrative costs in the monthly funding on a quarterly basis. The adjustment will be made after receipt of actual hospital invoices from MDCH. The Agency will allow MCPN subcontractors who have historically billed on the 3806 form to continue using this form until further notice. However, the MCPN must convert that bill to the requisite data format outlined by the Agency and submit the data to the Agency timely. The MCPN has full responsibility for errors or data conversion and submission. Given the importance of accurate data submission and the movement to standardization of data as outlined in HIPAA 121 regulations, the Agency reserves the right to rescind this exception with 30 days notice to the MCPNs The Provider MIS number, Eligibility Verification, Primary Diagnosis (that is psychiatric) must be submitted along with Patient Name and Demographics, Client Identification number, Case Number, Admit Date, Days Authorized, and Revenue Codes. D-WCCMHA Benefit Plan and Covered Services: The Agency is responsible to manage the following programs: Medicaid, Adult Benefit Waiver (ABW), MI-Child and the General Fund consistent with Michigan’s State Waivers, and the Michigan Department of Community (MDCH) contracts, policy guidelines, and technical advisories. As the PIHP and CMHSP for the Detroit–Wayne County service area, the Agency has established the overall eligibility/admission criteria and covered services to be contained within each of these four (4) benefit plans. All persons entering the public mental health and substance abuse systems, including Medicaid recipients, shall meet the clinical admission criteria specified in their respective benefit plan(s). All MCPNs and providers will be expected to implement systems to adhere to the Agency Benefit Plans and Benefit Plan Covered Services grid. (See Appendix IX) 122 Claim and Encounter Submission 123 Claim and Encounter Submission Information to Include on a Claim/Encounter Form For a claim to be considered a clean claim, it must: Include a valid member identification number Indicate patient’s name, address, birth date Indicate the day, month, and year the service was provided Be submitted within 1 year of the date of service (or discharge date for a facility) Include all relevant provider information including Provider name National Provider Identifier (NPI) Location of service Provider identification number (if different from NPI) Include a description of the covered service using Agency accepted codes stated in the contract, CPT codes, or other codes required by the State of Michigan Include a valid diagnosis code Only be submitted for services covered Have all fields necessary for accurate payment completed The MCPN, CA, Agency or any organization paying Medicaid claims must pay 90% of clean claims within 30 days and 99% within 90 days of receipt of the claim. Web-Based Encounter Submission Only direct contract providers (non-MCPN contractors) may submit encounter data to the Agency through the web-based application, MH-WIN. Electronic submission of data is still available to the direct contract providers using the 837 format. It is critical that all data be submitted accurately. 124 Compliance 125 Compliance Overview The Michigan Department of Community Health (MDCH) has changed its relationship to the Community Mental Health Service Programs (CMHSPs) in the state. MDCH no longer identifies as a provider of services but is now rather a purchaser of Behavioral Health Services and as a result is placing greater emphasis at the local level to understand and meet not only State requirements but also Federal regulations. The Compliance Division of the Agency was created to provide regulatory management and oversight regarding regulatory issues that impact / govern organizations that receive Medicaid and Medicare funding. This means the Compliance Division has a general review and oversight function regarding implementation of the major laws, regulations, rules, protocols, standards and contractual terms that govern the Agency’s activities directly and through its established mechanisms for providing mental health services. The Agency has a Compliance Plan approved by its Board of Directors that establishes regulatory management activities that will be coordinated across the network. Those activities include coordination of analytic resources devoted to regulatory identification, comprehension, interpretation and dissemination; the identification of various tools to promote regulatory compliance; review teams, and compliance audits and enforcement (sanctions). There is an established Code of Ethics to which each MCPN and its sub- contractors will be expected to adhere. Each MCPN will be expected to develop its own Compliance Plan. Each MCPN Compliance Plan must be submitted to the Agency’s Compliance Division for review and approval prior to January 1, 2003. At a minimum each Compliance Plan should incorporate the seven standards given in the federal Sentencing Guidelines as evidence of a health care provider’s due diligence. (United States Sentencing Commission Guidelines 1991) The Agency’s Compliance Division will monitor implementation of each MCPN’s Compliance Plan. Fraud and Abuse A primary element of the Agency’s Compliance Plan is to advance the prevention of fraud, abuse, and waste in providing health care and to detect misconduct or wrongdoing as soon as it occurs so that the problem can be quickly remedied and adverse consequences can be minimized. The Compliance Division of the Agency has oversight responsibility for the audits conducted to verify the provision of Medicaid services. Each MCPN should have a methodology for the verification of the provision of Medicaid services. 126 Key regulations that MCPNs, CAs, and their subcontractors are required to be compliant with include: The False Claims Act 31 U.S.C. 3799, The Anti-Kickback statute 42 U.S.C. 1320a-7b(b), The Anti-Self-Referral Statute 42 U.S.C. Section 1395nn (Stark I), The Omnibus Budget Reconciliation Act of 1993 (Stark II), The Deficit Reduction Act (PL 109.171), The Examination and Treatment for Emergency Medical Conditions and Women in Labor statute 42 U.S.C. 1395dd, and The Health Insurance Portability and Accountability Act of 1996. Health Insurance Portability and Accountability Act (HIPAA) In addition to the key provisions of HIPPA relating to fraud and abuse including mandatory exclusion from Medicare and Medicaid of providers who violate fraud and abuse provisions, there are HIPAA standards regarding transactions, privacy and security. Agency Policies Compliance Plan Policy: establishes the requirement of a Compliance Plan and a (Compliance) Program within the Agency and for MCPNs, CAs, and their subcontractors provided that they receive a minimum of five million in annual revenue from Medicaid/Medicare. Compliance Issue Investigation Policy: provides a process for Agency investigation of compliance issues brought to the attention of the Compliance Division. Periodic Compliance Audit Policy: establishes a procedure for the performance of periodic compliance audits. Policy on the Michigan Whistle- Blowers’ Protection Act: sets forth in writing the Agency’s commitment to adhere to the state and federal Whistle-Blowers’ Protection Act and to establish procedures to accomplish such compliance. Verification of Provision of Medicaid Services: establishes requirement for development of a methodology for verifying that services to Medicaid eligible Consumers were provided according to applicable laws and regulations. NOTE: The above references are not meant to be all-inclusive. Health Care Compliance Resources: U.S. Department of Health and Human Services, Office of the Inspector General website: www.hhs.gov/oig. Health Care Compliance Association website: www.hcca-info.org. The Health Care Corporate Compliance website: www.complianceinfo.com. Center for Medicare and Medicaid Services website: www.cms.gov. 127 Contacts 128 Contacts The following is a list of key agencies and their most recent contact information. This list includes organizations both in and outside of the D-WCCMHA network. Agency Contractors D-WCCMHA Access and Referral Services Information/Referral/Crisis Intervention: 1-866-289-2641 (24-hour Toll Free) TDY Line: 1-866-870-2599 (Information/Referral/Crisis Intervention/UR) (24-hour Toll Free) Utilization Review: Services Requiring Authorization: 1-866-690-8257 (24-hour Toll Free) Fax: 1-866-203-0733 Substance Abuse Coordinating Agencies Bureau of Substance Abuse, Prevention, Treatment, and Recovery Central Diagnostic and Referral Services (CDRS) Toll Free Telephone Access: 800-467-2452 Herman Kiefer Health Complex 1151 Taylor, Building #1 Detroit, Michigan 48202 CDRS business hours: Monday – Thursday 7:00 am to 7:00 pm; Friday 7:00 am to 5:00 pm Southeast Michigan Community Alliance Toll Free Telephone Access and Referral: 800-686-6543 (24-hour coverage) 25363 Eureka Road Taylor, MI 48180 SEMCA business Hours: Monday through Friday 8:30 am to 5:30 pm. After hours calls are forwarded to an answering service. Staff members are available to respond. State Hospitals Telephone Numbers Caro Center 2000 Chambers Caro, MI 48723 989-673-3191 Hawthorne 248-349-3000 129 18471 Haggerty Road Northville, MI 48167 Kalamazoo Psychiatric Hospital Box A, 1312 Oakland Dr. Kalamazoo, MI 49008 269-337-3000 Walter Reuther Psychiatric Hospital 30901 Palmer Road Wetland, MI 48185 734-367-8400 130 Detroit-Wayne County Community Mental Health Agency Managers of Comprehensive Provider Networks (MCPNs) CONTACT LIST NAME PARTNERS CEO ADDRESS PHONE, FAX & E-MAIL CONTACT PERSON FOR NOTIFICATION OF PERSON’S CHOICE PHONE, FAX & E-MAIL CONSUMER INFORMATION PHONE TDY CareLink Network: Children’s Center Development Centers, Inc. Hegira Programs, Inc. Neighborhood Service Org. New Center CMHS Northeast Guidance Center Southwest Counseling The Guidance Center David Schmehl President – CEO, BHPI Doreen Nied Executive Director Toll Free: (888) 711-5465 TDD: (313) 649-3777 1333 Brewery Park Suite #300 Detroit, MI 48207 (313) 656-0000 (M) (313) 656-0041 (O) (313) 656-2589 (F) www.bhpi.org Gateway: Psychiatry & Behavioral Medicine Professionals Metro Emergency Services Mitchell Hall CEO/President 3011 West Grand Blvd. Detroit, MI 48202 1333 Brewery Park Suite #300 Detroit, MI 48207 (313) 831-5535 (O) (313) 831-7421 (F) (313) 262-5100 (O) (313) 875-4715 or 4723 (F) Synergy Partners: Adult Well-Being Services Family & Neighborhood Services Goodwill Industries of Greater Detroit Pathways Development Corporation Wayne Center Isadore King President & CEO New Center One Building 3031 West Grand Blvd Suite 555 Detroit, MI 48202 Main Line (313) 262-5100 Toll Free (800) 973-4283 TDD (800) 915-4283 Web Site: www.gchi.org Toll Free (866) 724-7544 TDD (800) 223-5822 Office Number (313) 748 7400 www.synergypartnersllc.com (313) 748-7400 EXT. 103 (O) (313) 748-7405 (F) 131 Detroit-Wayne County Community Mental Health Agency Managers of Comprehensive Provider Networks (MCPNs) CONTACT LIST NAME PARTNERS CEO ADDRESS PHONE, FAX & E-MAIL CONTACT PERSON FOR NOTIFICATION OF PERSON’S CHOICE PHONE, FAX & E-MAIL CONSUMER INFORMATION PHONE TDY Consumer Link Network: Children’s Center Development Centers, Inc. Hegira Programs, Inc. Neighborhood Service Org. New Center CMHS Northeast Guidance Center Southwest Counseling The Guidance Center David Schmehl President – CEO, BHPI David Pankotai Executive Director-Consumer Link 1333 Brewery Park Suite #300 Detroit, MI 48207 Toll Free (888)-711-5465 TDD (800)-649-3777 Community Living Services (CLS): James L. Dehem President/CEO Metro Place Center 35425 W. Michigan Ave. Wayne, MI 48184-1687 Customer Service Attn: Helen Long-Easy Metro Place Center 35425 W. Michigan Ave. Wayne, MI 48184-1687 (734) 722-4010 (O) (734) 467-7639 (F) (734) 722-5487 (O) (734) 467-7639 (F) jdehem@comlivserv.com hlong@comlivserv.com 1333 Brewery Park Suite #300 Detroit, MI 48207 (313) 831-5535 (O) (313) 831-7421 (F) Web Site: www.bhpi.org (313) 656-0000, Ext. 1004 (O) (313)-656-2589 (F) Toll Free : (866) 381-7600 Main Line: (734) 467-7600 x1158 TDD: (734) 467-7600 x1565 www.comlivserv.com 132 Robert A. Ficano Juvenile Services Division County Executive Juvenile Services - Agency Contact List Care Management Organizations (CMO) Black Family Development, Inc. Alice Thompson, Executive Director 5555 Conner, Suite 1E21 Detroit, MI 48213 (313) 308-0255 (313) 308-0270, fax After Hours Emergency Pager No. – (313) 684-5070 Ms. Stevia Simpson-Ross, Vice President of Juvenile Justice sross@blackfamilydevelopment.org Bridgeway Services, Inc. Kari Walker, Board Member 19265 Northline Road Southgate, MI 48195 (734) 284-4819 (734) 287-2948, fax After Hours Emergency Pager Numbers – The Guidance Center (734) 626-4195; Southwest Counseling Solutions (313) 967-7820 Ms. Susan Shuryan, Director SShuryan@bridgewayservices.org Center for Youth & Families Ms. Jeri Fisher, Executive Director Central Care Management Organization (CMO) New Center One, Suite 370 3031 West Grand Boulevard Detroit, MI 48202 (313) 875-2092 (313) 875-2192, fax – (313) 875-2391, alternate fax After Hours Emergency Number (313) 875-2092, then press 8 to get connected to emergency cell number. Jeri Fisher, CEO jeri.fisher@ccmorg.org StarrVista Chuck Jackson, Executive Director mailto:jacksonwc@starrvista.org 22390 W. Seven Mile Detroit, MI 48219 (313) 387-6000 (313) 387-0760, fax After Hours Emergency Pager Number (313) 684-2904 or (313) 387-6000 (Emergency Information) Ms. Michelle Rowser, Director of Operations rowserm@starrvista.org 133 Western Wayne CMO (Growth Works) Dale Yagiela, Executive Director dyagiela@growth-works.org 271 S. Main Plymouth, MI 48170 (734) 455-4095 (734) 455-2664, fax After Hours Emergency Pager Numbers – (888) 306-3405 Ms. April Wyncott, Program Director awyncott@growth-works.org Juvenile Assessment Center (JAC) Juvenile Assessment Center (JAC) 7310 Woodward Ave., Suite 601 Detroit, MI 48202 (313) 896-1444 (313) 896-1466, fax or 896-1524 Ms. Cynthia Smith, Executive Director Cyndi Smith, Executive Director csmith@assuredfamilyservices.org 134 Medicaid Health Plans Below is a list of Medicaid Qualified Health Plans (MHP) contracted to operate in Detroit-Wayne County with corresponding contact information and web addresses. Telephone Access to the plans is available 24 hours per day, 7 days per week. This list is periodically up dated by the Michigan Department of Community Health and can be found at www.mdch.state.mi.us. Go to Medical Services Administration, click on “Medicaid Programs”, then, click on “Listing of Health Plans,” or paste in your browser the following web address: http://michigan.gov/mdch/0,1607,7-132-2943_4860-41361-,00.html. Use these links to obtain contact numbers, hyperlinks, and locations, to contact the MHP for further information on locating the primary care provider. Also available on the MHP websites are membership information, customer service contacts, and the corresponding MHP’s Membership Handbooks, list all membership benefits and services. Note: All health plans have a 12-month lock-in period of enrollment before enrollment in another health plan can be considered. BlueCaid of Michigan 20500 Civic Center Drive Southfield, Mi, 48076 (800) 228-8554 (Member Service) (800) 649-3777 (TTY) http://www.mibcn.com/member/BlueCaid/ Molina Healthcare of Michigan 100 W. Big Beaver Road, Suite 600 Troy Mi, 48084 (248) 925-1700 (888) 898-7969 (Member Service) http://www.molinahealthcare.com Great Lakes Health Plan, Inc. 17117 W. Nine Mile, Suite 1600 Southfield, Mi, 48075 (248) 559-5656 (800) 903-5253 (Member Service) 711 (TTY) (800) 642-3195 (Medicaid Help Line) http://www.glhp.com OmniCare Health Plan 1333 Gratiot, Suite 400 Detroit, Mi, 48207 (313) 465-1564 (866) 316-3784 (Member Service) (866) 318-3784 (TDD) http://www.omnicarehealthplan.com Health Plan of Michigan 17515 W. Nine Mile road, Suite 500 Southfield, Mi, 48075 (248) 557-3700 (888) 437-0606 (Member Service) (800) 649-3777 (TTY) http://www.hpmich.com Midwest Health Plan 5050 Schaefer road Dearborn Mi, 48126 (313) 581-3700 (888) 654-2200 (Member Service) (800) 642-3195 (Medicaid Help Line) (800) 649-3777 (TTY) http://www.midwesthealthplan.com ProCare Health Plan, Inc. 3956 Mt. Elliott Detroit, Mi, 48207 (313) 267-0300 (877) 255-3055 (Member Service) http://www.procarehp.com Total Health Care 3011 W. Grand Blvd., Suite 1600 Detroit, Mi, 48202 (313) 871-2000 (800) 826-2862 (Member Service) (800) 649-3777 (TTY) (800) 642-3195 (Medicaid Hot Line) http://www.totalhealthcareonline.com 135 Uninsured Health Providers Community Care Associates, Inc. 2111 Woodward - Suite 400 Detroit, Mi 48201 313-961-3100 Office 313-961-3116 Fax Midwest Health 5050 Schaefer Road Dearborn, MI 48126 313-586-6064 (W) 313-586-8699 (Fax) ProCare Health Plan, Inc. 3956 Mt. Elliott Detroit, Mi, 48207 (313) 267-0300 (877) 255-3055 (Member Service) http://www.procarehp.com 136 Definitions 137 Definitions Detroit-Wayne County Community Mental Health Agency KEY TERMS/PHRASES TERM Access Center Acknowledgement Letter Acute Crisis, Intervention Home Administrative Efficiencies Administrative Fair, Hearing or Medicaid Fair Hearing Adult Foster Care Home (Adults ages 18 and over) Advance Directives Adverse Action Agency AFP Appeal DEFINITIONS Centralized calling center for the Agency’s public mental health services. The Access Center provides information on a wide variety of services, recommends where help can be obtained and assists in scheduling appointments, The Access Center is available to all Wayne County residents, 24 hours a day, 7 days a week. A letter acknowledging receipt of the consumer’s grievance. Short-term services provided in a protected residential setting under the supervision of a Qualified Mental Health Professional for developmentally disabled adults who also have mental illness and are experiencing an acute exacerbation of the illness. The ability to produce a desired effect in with a minimum of effort, expense, or waste as applied to management functions of the organizations. An impartial review process maintained by the MDCH to ensure that Medicaid beneficiaries or their legal, representatives involved in a community Mental Health Services Program have the opportunity to appeal decisions of the Agency or its representatives which result in the denial, suspension, reduction or termination of Medicaid covered services. A Medicaid beneficiary or any person entitled to services may request a hearing within 90 days of notice of the denial, suspension, reduction or termination of Medicaid-covered benefits. Adult Foster Care is a general licensed living arrangement that may accommodate one or more residents. Residents in this setting have mild to no maladaptive behaviors and may or may not require assistance with community living and self care tasks. Specialized services can be arranged and provided in this setting if indicated. A legal document, signed by a competent adult that gives direction to healthcare providers about the consumer's treatment choices in specific circumstances, including but not limited, to medical or psychiatric conditions, should the consumer become unable to make or communicate healthcare decisions. A denial, suspension, reduction or termination of mental health services, except as ordered by a physician's determination of absence of medical necessity. Detroit-Wayne County Community Mental Health Agency, a community mental health services program established and administered pursuant to provision of the State Mental Health Code, for the purpose of providing a comprehensive array of mental health services appropriate to the condition of individuals who are Wayne County residents, regardless of ability to pay. MDCH's required Application for Participation. A process established by MDCH to provide a mechanism for prompt reporting, review, investigation, and resolution of 138 KEY TERMS/PHRASES TERM Assertive Treatment (ACT) Community Authorization Beneficiary Best Value CAFAS Capitation Categorical Funds CCH Certification Certified Peer Specialist (CPSS) CFAC Support DEFINITIONS apparent or suspected violations of the rights guaranteed by the Mental Health Code. From the Consumer Handbook as approved by the State Jan 2008 ACT provides basic services and supports essential for people with serious mental illness to maintain independence in the community. An ACT team will provide mental health therapy and help with medications. The team may also help access community resources and supports needed to maintain wellness and participate in social, educational and vocational activities. Assertive Community Treatment (ACT) is a comprehensive and integrated set of medical and psychosocial services provided on a one-to-one basis primarily in the client's residence or other community locations (non-office setting) by a mobile multidisciplinary mental health treatment team. The team provides an array of essential treatment and psychosocial interventions for individuals who would otherwise require more intensive and restrictive services. The team provides additional services essential to maintaining an individual's ability to function in community settings. This would include assistance with addressing basic needs, such as food, housing, and medical care and supports to allow individuals to function in social, educational, and vocational settings A decision rendered by a Qualified Professional to approve a request for clinical services Consumers who are Medicaid-eligible. A process used in competitive negotiated contracting to select the most advantageous offer by evaluating and comparing factors in addition to cost or price. Child and Adolescent Functional Assessment Scale Fixed amount paid per month per Person to the MCPN for Covered Services. Funds that are designated for a specific service, program and/or special population. Contracted Community Hospital that provides acute inpatient and/or partial hospitalization services by contract with the Agency. Certification is a process of evaluating/screening clients to determine and approve appropriate and clinically necessary services for inpatient psychiatric admission, and other prior authorized services, which includes certifying appropriateness of all inpatient hospital and physician services related to the admitting mental health diagnosis, including laboratory and x-ray services, medications, etc. Any inpatient psychiatric admission not certified by the CMH is not a benefit of the Medicaid program. Individuals who have a mental illness, substance use or cooccurring disorder, have been through the recovery process, have been trained and certified to assist others who arein need of recovery services and supports. CPSS are trained to connect consumers to numerous supports and services needed in recovery. Consumer Family Advocate Council is a Consumer-driven advisory group that serves as a communication link to individuals receiving services from DWCCMHA. It provides consumers an 139 KEY TERMS/PHRASES TERM Child Mental Professional Health Children's Diagnostic Treatment Service and Clean Claim CM CMH CMHP CMS Community Mental Health Services Program (CMHSP) Community Behavioral Health Management Initiative Complaint Consumer Contact Letter Satisfaction Consumers Contracted Provider Co-occurring Disorders DEFINITIONS opportunity to participate in the planning nad policy-making process that affects them in the design and delivery of mental health services. One of the following: a) A person who is trained and has one year of experience in the examination, evaluation, and treatment of minors and their families and who is one of the following: i. A physician ii. A psychologist iii. A certified social worker or social worker; iv. A registered nurse; OR b) A person with at least a bachelor's degree in a mental health-related field from an accredited school who is trained, and has three (3) years of supervised experience, in the examination, evaluation, and treatment of minors and their families. OR c) A person with at least a master's degree in a mental health-related field from an accredited school who is trained and has one year of experience, in the examination, evaluation, and treatment of minors and their families. A program operated by or under contract with a Community Mental Health Services Program, which provides examination, evaluation and referrals for minors, including emergency referrals, that provides or facilitates treatment for minors, and that has been certified by MDCH. A clean claim is one that can be processed without obtaining additional information from the provider of the service or a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. As stated in the FY 02 State Appropriation Act (P.A. 60), a clean claim that is not paid within 45 days after receipt shall bear simple interest at a rate of 12% per annum. Case Manager/qualified primary case manager Community Mental Health Child Mental Health Professional Centers for Medicare and Medicaid Services A program operated under Chapter 2 of the Michigan Mental Health Code – Act 258 of 1974 as amended. The Agency's contracted administrative service organization having responsibilities for information, referral, utilization review, and other identified services operated by Behavioral Health as the Detroit Regional Service Center. An oral or written statement made to the Office of Recipient Rights (ORR) alleging violation of a Mental Health Code protected right. A letter forwarded to the beneficiary prior to the 60th calendar day requesting a satisfaction response to the resolution of his/her grievance after all other contact attempts have been unsuccessful. Recipients of services designated by two types: Primary and Secondary. Primary refers to the recipient of services. Secondary refers to family members of the primary recipient. An individual or entity participating in the Provider Network pursuant to a contract with the MCPN to provide When used in the context of Consumers, this term refers to co140 KEY TERMS/PHRASES TERM Coordinating Agency (CA) Covered Services. Cultural Competency Customers Denial Dependent Living Setting Developmental Disability DEFINITIONS occurring psychiatric and/or substance use disorders. A legal entity under contract with the Agency to provide any substance abuse service as defined by the agency and is not a MCPM. Covered Services Specialty supports and services. A set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between cultural groups. This requires a willingness, and ability to draw on community-based values, traditions, and customs, and to work with knowledgeable individuals of, and from, the community in developing targeted interventions, communications and other supports to address the unique needs of specific population groups. An acceptance and respect for difference, a continuing self-assessment regarding culture, a regard for and attention to the dynamics of difference, engagement in ongoing development of cultural knowledge, and resources and flexibility within service models to work toward better meeting the needs of the minority populations. The cultural competency of an organization is demonstrated by its policies and practices. In this Agreement, a potential recipient of Covered Services, which includes all people located in the defined service area. An adverse decision made by a psychiatrist regarding a request to authorize services, after appropriate evaluation of relevant clinical information. a) An Adult Foster Care facility b) A nursing home c) A Home for the Aged d) Child Caring Institution Means either of the following: 1. If applied to an individual older than five years, a severe, chronic condition that meets all of the following requirements: a. Is attributable to a mental or physical impairment or a combination of mental and physical impairments, b. Is manifested before the individual is 22 years old, c. Is likely to continue indefinitely, d. Results in substantial functional limitations in three or more of the following areas of major life activities: (1) self care, (2) receptive and expressive language, (3) learning, mobility, (4) self-direction, (5) capacity for independent living, (6) economic self-sufficiency, e. Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. 2. If applied to a minor from birth to age five, a substantial developmental delay or a specific congenital or acquired condition with a high probability of resulting in developmental disability as defined in item 1 if services are not provided. 141 KEY TERMS/PHRASES TERM Direct Contractor Dual Diagnosis Early On Program Effective Freedom Emergency Situation Encounter Enhanced Health Services DEFINITIONS A legal entity or entities contracted with the Agency to provide community mental health services/supports (often known as program services) as defined by the agency and is not a MCPN. A person with a two or more of the following diagnoses: mental illness, developmental disability, Serious emotional disability and/or substance abuse disorder. Early On services are delivered to children ages 0 to 3 identified either with a developmental delay or developmental disability. Early On services provide infant mental heath services to families with children between the ages of 0 to 3, who have been identified as "at risk" for an out of home placement due to parenting problems such as substance abuse, mental illness, physical abuse, or neglect. Additional services include clinicbased and home-based services for children between the ages of 3 to 5. These services shall be designed and delivered in such a manner as a) to provide an aftercare option for children who were discharged from Early On services or infant mental health services due to reaching the age limitation; b) to provide a transitional option for children who were discharged from Early On services or infant mental health services due to achieving their treatment goals; c) to provide services to families with children ages 3 to 5, who have been identified as "at risk" for an out-ofhome placement due to parenting problems such as substance abuse, mental illness, physical abuse or neglect. The realization of social citizenship and full community membership. Citizens are able to build upon basic freedoms – to effectively unlock the potential of liberty – by making choices, pursing personal goals, engaging in productive activity, establishing a wide range of associations and relationships, participating in community events, and living in real homes. A situation in which an individual is experiencing a severe mental illness or a developmental disability, or a child is experiencing a serious emotional disturbance, and one of the following apply: 1. The individual can reasonably be expected within the near future to physically injure himself, herself, or another individual, either intentionally or unintentionally. 2. The individual is unable to provide himself or herself food, clothing, or shelter, or to attend to basic physical activities such as eating, toileting, bathing, grooming, dressing, or ambulating, and this inability may lead in the near future to harm to the individual or to another individual. 3. The individual's judgment is so impaired that he or she is unable to understand the need for treatment and, in the opinion of the mental health professional, his or her continued behavior as a result of the mental illness, developmental disability, or emotional disturbance can reasonably be expected in the near future to result in physical harm to the individual or to another individual. A document submitted in a claim format specified by the Agency that documents the services and costs of services provided to a consumer. Those services beyond the responsibility of the Person's health 142 KEY TERMS/PHRASES TERM DEFINITIONS Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Expedited Appeal Extended Hour Hold Observation –23 Facility FIA Formal Grievance Grievance Grievance Process HCFA Health Insurance Portability and Accountability Act of plan, that are provided for rehabilitative purposes to improve the Person's overall health and ability to care for health-related needs. This includes nursing services, dietary/ nutrition services, maintenance of health and hygiene, teaching self-administration of medication, care of minor injuries or first aid, and teaching the Person to seek assistance in case of emergencies. Services must be provided according to the professional's scope of practice and under appropriate supervision. Enhanced health services must be carefully coordinated with the Person's health care plan. Federal regulations require state Medicaid programs to offer early and periodic screening, diagnosis, and treatment (EPSDT) to eligible Medicaid beneficiaries less than 21 years of age. The intent is to find and treat problems early so they do not become more serious and costly. The expeditious review of an action, requested by a beneficiary or the beneficiary’s provider, when the time necessary for normal appeal review process could seriously jeopardize the beneficiary’s life, health or ability to attain, maintain, or regain maximum function. It the beneficiary requests the expedited review, the service provider determines if the request is warranted. If the beneficiary’s provider makes the request, or supports the beneficiary’s request, the service provider must grant the request. Medically staffed, psychiatrically supervised service of less than 24 hours in duration designed for individuals who, as the result of a psychiatric disorder, are transiently at risk of harm, temporarily unable to meet basic needs, or provisionally impaired in functioning and require medical observation and a protective environment. A residential building for the care or treatment of individuals with severe mental illness, serious emotional disturbance, or developmental disability that is either a state facility or a licensed facility. Family Independence Agency is the Agency that determines eligibility for Michigan’s Medicaid Program A grievance initiated at the Agency Customer Service Unit for follow-up and resolution. A process for expressing dissatisfaction with an actual or supposed circumstance regarded by the complainant as just cause for protest about mental health treatment/services/supports, managed and/or delivered by the Agency network, made in accordance with the Mental Health Code, with available assistance of an ORR representative, as needed. An impartial local level review of a Medicaid beneficiary’s grievance (expression of dissatisfaction) about PIHP/CMHSP service issues other than an action. Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services. Public Law 104-191, 1996 to improve the Medicare program under the title XVIII of the Social Security Act, the Medicaid program 143 KEY TERMS/PHRASES TERM 1996 (HIPAA) DEFINITIONS under the title XIX of the Social Security Act, and the efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of standards and requirements for the electronic transmission of certain health information. The Act provides for improved portability of health benefits and enables better defense against abuse and fraud, reduces administrative costs by standardizing format of specific healthcare information to facilitate electronic claims directly addresses confidentiality and security of patient information – electronic and paper-based, and mandates "best effort" compliance. Individual Informal Grievance Initial Assessment Intensive (ICR) Crisis Residential Intensive Crisis Stabilization Intensive Crisis Stabilization HIPAA mandates, among others, that the following requirements must be implemented: 1. Data integrity, confidentiality, and availability guards 2. Access control (user-based, role-based, and availability) 3. Audit controls (user-based, role-based) 4. Data authentication (automatic log-off, unique user ID, password, PIN, biometrics, token, or telephone callback) 5. Unauthorized access guards 6. Communications/network controls (access controls, encryption, integrity controls or message authentication) 7. Network controls (alarm, audit trail, entity authentication, event reporting, user-based, role-based, or context-based access) Consumers with mental illness, developmental disabilities, or substance use disorders (or a combination of disabilities). For the purpose of this application, includes Consumers who are Medicaid-eligible, as well as other mental health and substance abuse specialty services recipients who may be indigent, are selfpay, or have private insurance coverage. A grievance initiated at the MCPN/CA, Direct Contractor, and Subcontractor’s level for follow-up and resolution. Term used in substance abuse service. It is a process that collects sufficient information to determine a level of care based on at least the six dimensions of the American Society of Addiction Medicine Patient Placement Criteria. This initial assessment process also gathers enough information to determine an initial diagnostic impression using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Short term intensive treatment services provided in a protected residential setting as an alternative to inpatient hospital admission when clinically appropriate for people experiencing acute psychiatric crisis diagnosed by a Qualified Mental Health Professional, as meeting criteria for an acute inpatient hospital admission. The mentally ill adult must have symptoms that can be stabilized in an alternative community setting. The process of stabilizing an individual in acute crisis to avert a psychiatric admission or to shorten the length of an inpatient stay. Structured treatment and support activities provided by a mental 144 KEY TERMS/PHRASES TERM Services IPOS ITT I-Team Jail Diversion Legal Representative Level of Care (LOC) Severity of Illness/Intensity of Service Limited – English Proficiency (LEP) Linguistically Services MACMHB MCO MCPN MCPN Manual MDCH Appropriate DEFINITIONS health crisis team, under psychiatric supervision and designed to provide a short-term treatment alternative to inpatient psychiatric services. Services should be used to avert a psychiatric admission or to shorten the length of an inpatient stay. Individual Plan of Service Interdisciplinary Treatment Team Agency Inter-Divisional Team A collaborative, integrated program utilizing a community's resources to divert a person with severe mental illness serious emotional disturbance or developmental disability from possible jail incarceration when appropriate. The representative, parent of a minor or other person authorized by law to represent an applicant or consumer. Protocols provided by the Michigan Department of Community Health (MDCH) and the Agency, each as amended from time to time, as part of a utilization management system, which is intended to monitor the appropriateness of mental health care. Severity of Illness refers to the nature and severity of the signs, symptoms, functional impairments, and risk potential related to the person's complaint. Intensity of Service pertains to the setting of care, to the types and frequency of needed services and supports, and to the degree of restriction necessary to safely and effectively treat the individual. Consumers who cannot speak, write, read or understand the English language in a manner that permits them to interact effectively with health care providers and social services agencies. Provided in the language best understood by the consumer through bilingual staff and the use of qualified interpreters, including American Sign Language, to individuals with limitedEnglish proficiency. These services are a core element of cultural competency and reflect an understanding, acceptance, and respect for the cultural values, beliefs, and practices of the community of individuals with limited-English proficiency. Linguistically appropriate services must be available at the point of entry into the system and throughout the course of treatment, and must be available at no cost to the consumer. Michigan Association of Community Mental Health Boards Managed Care Organization Manager of a comprehensive provider network contracting with the Agency. For each Manager of Comprehensive Provider Network Contract, MCPN shall include all parties to such agreement other than the Agency. The manual developed and implemented by the Agency, and adopted by the MCPN, that includes all policies, procedures, forms, instructional materials, and other information used to support and supervise/manage the Provider Network, in accordance with Agency guidelines. Michigan Department of Community Health, State of Michigan. The State division is responsible for funding a comprehensive array of specialty mental health services for Consumers with severe mental illness and children with serious emotional disturbances 145 KEY TERMS/PHRASES TERM Medicaid Eligible Medicaid Fair Hearing (MFH) Mental Health Professional MI Child MIPath MORC MRS Multicultural Services No Grievance Involved Non-Categorical Funds OBRA Office (ORR) of Recipient Out-of-Area Services Rights DEFINITIONS and specialty services for Consumers with developmental disabilities and to priority populations as defined in the Michigan Mental Health Code. Using established criteria to recommend or evaluate the medical necessity of services, effective use of resources, and costeffectiveness. Individual who has been determined to be eligible for Medicaid by the State of Michigan. An impartial state level review of a Medicaid beneficiary’s appeal of an action presided over by a MDCH Administrative Law Judge. It is also referred to as an “Administrative Hearing.” A person who is trained and experienced in the areas of mental illness or mental retardation and who is any one of the following: 1. A physician who is licensed to practice medicine or osteopathic medicine in Michigan and who has substantial experience with mentally ill or developmentally disabled recipients for one year immediately preceding his/her involvement with a recipient under these rules; 2. A psychologist 3. A certified social worker 4. A registered nurse 5. A professional person, other than those defined in this rule, which is designated by the director in written policies and procedures. This mental health professional shall have a degree in his or her profession and shall be recognized by his or her respective professional association as being trained and experienced in the field of mental health. A health insurance program offered through the State of Michigan for the uninsured children of Michigan's working families; eligibility requirements are established by the State. A workshop organized by trained leaders that help participants improve their health and feel better about themselves, physically and mentally. Participation in MiPath workshops by consumers must be documented in their Person Centered Plan. Macomb Oakland Regional Center Michigan Rehabilitation Services, now known as the Michigan Department of Career Development—Rehabilitation Services. Specialized mental health services for multicultural populations such as African-Americans, Hispanics, Native Americans, Asian and Pacific Islanders, and Arab/Chaldean-Americans. The complaint presented does not meet the mandate or definition of a grievance as outlined by the State. Funds that are not designated for any specific programs, services or special populations. Omnibus Budget Reconciliation Act of 1987; 1990 is Federally mandated legislation establishing programs and a funding program that was developed in 1989. Division of the Agency established in accordance with the Michigan Mental Health Code to ensure a uniformly high standard of protection of the rights of the recipients throughout the State. These are services provided to Wayne County consumers by out146 KEY TERMS/PHRASES TERM Out of Jurisdiction Letter Out-of-Network Services Outreach PASARR Peer Mentoring Person Person-Centered Planning or PCP Per-Member-Per-Month (PMPM) DEFINITIONS of-area service providers who are not part of the Detroit-Wayne County Community Mental Health Network. Typically, special "purchase of service" arrangements are negotiated with the outof-area provider or responsible CMHSP for that area, to provide the service(s). While the Agency's MCPNs are expected to have a countywide network, there may be occasions when the MCPN may need to secure such service provisions as out-of-area on a temporary time targeted basis. There are times when such services may have to be obtained out of state, however, these out-of-area and out of state services will need to be authorized, paid and monitored by the MCPN. Transportation should be provided when necessary. A letter sent to the consumer, parent or legal representative stating that his/her complaint is outside of the Detroit-Wayne Community Mental Health Services jurisdiction. Services provided by a mental health professional who does not participate in the Provider Network. Out-of-Network services also refers to services provided outside of the Person’s MCPN, but within the network Efforts to extend services to those Consumers who are underserved or hard-to-reach that often require seeking individuals in places where they are most likely to be found, including hospital emergency rooms, homeless shelters, women's shelters, senior centers, nursing homes, primary care clinics and similar locations. Preadmission screening and annual resident review are requirements of the OBRA program. Preadmission screening must be completed prior to placement of a person with mental illness in nursing homes. Annual review determines the need for continued nursing home care and whether specialized services for the mental illness are indicated. Provides essential services to individuals who have developmental disabilities so that they can become more proactive and responsible in improving the quality of their lives. Those trained as Peer Mentors assist persons in overcoming barriers and helps them achieve daily and long term goals in the following areas: community inclusion, education, transportation, advocacy, employment, housing, health and wellness, recreation and entitlements. Peer Mentors will also combat stigma in the community and in the workplace through education and selfdetermination. Individual with a Developmental Disability who qualifies for Covered Services and selects MCPN for such services. Process for planning and supporting an individual receiving services that builds upon the individual's capacity to engage in activities that promote community life and that honor the individual's preferences, choices, and abilities through the Public Mental Health System. The person-centered planning process involves families, friends, and professionals as the individual desires or requires. A fixed monthly rate per Medicaid eligible person monthly rate payable to the PHP by the MDCH for provision of all Medicaid services defined within this contract. 147 KEY TERMS/PHRASES TERM PHP PIHP Policy Manuals of the Medical Assistance Program Practice Guideline Prepaid Health Plan (PHP) Priority Population Provider Provider Network Provider Sponsored Specialty Networks (PSSN) Psychiatric Partial Hospitalization Program QMRP DEFINITIONS Pre-paid Health Plan Prepaid Inpatient Health Plan means an entity that (i) provides medical services to enrollees under contract with a State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates, (ii) provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees, (iii) does not have a comprehensive risk contract. The MDCH periodically issues notices or proposed policy for the Medicaid program. Once a policy is final, MDCH issues policy bulletins that explain the new policy and give its effective date. These documents represent official Medicaid policy and are included in the policy manual of the Medical Assistance Program. MDCH-developed guidelines for PHPs for specific service, support or systems models of practice that are derived from empirical research and sound theoretical construction and as applied to the implementation of public policy. MDCH guidelines issued prior to June 200 were called "Best Practice Guidelines". All guidelines are now referred to as Practice Guidelines. Organization that manages specialty health care services under the Michigan Medicaid Waiver Program for Specialty Services. Consumers who are at risk for developing serious emotional disturbance (SED) severe mental illness (SMI) or have developmental disabilities (DD). For purposes of managing specialized treatment and support services, SMI and SED are defined by diagnosis, degree of disability and/or duration of illness. A legal entity or independent practitioner contracted with the Agency or MCPN to provide services/ supports as specified by the Agency. The network of MCPN and all Contracted Providers established to deliver Covered Services to Recipients. Vertically integrated, comprehensive service entities that are organized and operated by affiliated groups of service providers that offer relatively complete "systems of care" for beneficiaries with particular service needs. The Agency uses the term MCPN as an alternative to PSSN. A nonresidential treatment program that provides psychiatric, psychological, social, occupational, nursing, music therapy, and therapeutic recreational services under the supervision of a physician to adults diagnosed as having severe mental illness or minors diagnosed as having serious emotional disturbance who do not require 24-hour continuous mental health care, and that is affiliated with a psychiatric hospital or psychiatric unit to which consumers may be transferred if they need inpatient psychiatric care. A Qualified Mental Retardation Professional is a person with specialized training or experience in treating or working with Consumers with mental retardation and is one of the following: 1. Educator with a degree in education from an accredited program. 2. Occupational therapist: 148 KEY TERMS/PHRASES TERM DEFINITIONS a. A graduate of an occupational therapy curriculum accredited jointly by the Council on Medical Education of the American Medical Association and the American Occupational Therapy Association; or b. Is eligible for certification by the American Occupational Therapy Association under its requirements; or c. Has two years of appropriate experience as an occupational therapist, and has achieved a satisfactory grade on an approved proficiency examination, except that such determination of proficiency does not apply to Consumers initially licensed by the State or seeking initial qualifications as an occupational therapist after December 31, 1977. 3. Physical therapist: a. Licensed as a physical therapist by the State b. has graduated from a physical therapy curriculum approved by the American Physical Therapy Association or by the Council on Medical Education and Hospitals of the American Medical Association c. Has two years of appropriate experience as a physical therapist, after December 31, 1977. 4. Physician of medicine or osteopathy, licensed by the State. 5. Psychologist with a master's degree from an accredited program. 6. Registered nurse: currently licensed by the State of Michigan 7. Social worker with a bachelor's degree in: a. social work from an accredited program; or b. in a field other than social work and at least three years of social work experience under the supervision of a qualified social worker. 8. Speech pathologist or audiologist (qualified consultant): a. Licensed by the State and is eligible for a certificate of clinical competence in speech pathology or audiology granted by the American Speech and Hearing Association; or b. Meets the educational requirements for certification, and is in the process of accumulating the supervised experience required for certification. 9. Therapeutic recreation specialist: a. Graduate of an accredited program; and b. Licensed or registered by the State. 10. Rehabilitation counselor: certified by the Committee on Rehabilitation Counselor for Certification. QPIC Qualified Health Plan (QHP) Qualified Mental Professional Reasonable Health Quality Performance and Improvement Council A health plan (e.g., HMO, PPO, POS) in which a Medicaid recipient may belong. The QHP pays for mental health services when a consumer is Medicaid eligible, but does not meet the DD, SMI or SED requirements. A qualified mental health professional is licensed, certified or registered by the State of Michigan or a national organization to provide mental health services and clinical and administrative supervision. Services are available within 30 miles or 30 minutes in urban areas, 149 KEY TERMS/PHRASES TERM Access(geographic standard) Recovery access Resolution Letter Respite Root cause analysis Screening Second Opinion/Reconsideration Sentinel Event Serious Emotional Disturbance DEFINITIONS or within 60 miles or 60 minutes in rural areas The over arching message of recovery is that hope and restoration of a meaningful life are possible, despite severe mental illness. Instead of focusing primarily on symptom relief, as the medical model dictates, recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society. A letter forwarded to the beneficiary explaining the action taken to resolve his/her grievance. Respite services are those services that are provided in the individual's/family's home or outside the home to temporarily relieve the unpaid primary caregiver. Respite services provide short-term care to a child with a mental illness/emotional disturbance to provide a brief period of rest or relief for the family from day to day care giving for a dependent family member. Respite programs can use a variety of methods to achieve the outcome of relief from care giving including family friends, trained respite workers, foster homes, residential treatment facilities, respite centers, camps and recreational facilities. Respite services are not intended to substitute for the services of paid support/training staff, crisis stabilization and crisis residential treatment or out-of-home placement. A structured and process-focused framework for identifying and evaluating the basis or causal factors involved in producing a sentinel event. The analysis should include the development of an action plan that identifies the steps that will be implemented to lessen the risk that similar events would happen to have happen. Means the CMH has been notified of the Person and has been provided enough information to make a determination of the most appropriate services. The screening may be provided onsite, face-to-face, by CMH personnel, or, over the telephone. An additional clinical evaluation and decision provided in response to a request from an applicant, authorized representative or referring mental health professional, in dispute of an adverse decision when: 1) A specific request for inpatient hospitalization has been denied by a psychiatrist reviewer, and 2) Following a face-to-face assessment by a qualified professional, determination is made that no mental health service is needed and the applicant is referred outside the Agency network to other human service resources. Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. A diagnosable mental, behavioral, or emotional disorder affecting a minor that exists or has existed during the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent diagnostic and statistical manual of mental disorders published by the American Psychiatric Association and approved by the MDCH, and that has resulted in functional 150 KEY TERMS/PHRASES TERM Severe mental illness Service Authorization Stakeholder Special Needs Residential for MIA and DD Consumers State Hospital Services Status Letter Substance Abuse DEFINITIONS impairment that substantially interferes with or limits the minor's role or functioning in family, school or community services. The following disorders are included only if they occur in conjunction with another diagnosable serious emotional disturbance: 1. A substance use disorder 2. A developmental disorder 3. A "V" code in the diagnostic and statistical manual of mental disorders Diagnosable mental, behavioral, or emotional disorder affecting an adult that exists or has existed within the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent diagnostic and statistical manual of mental disorders, published by the American Psychiatric Association and approved by the MDCH, in functional impairment that substantially interferes with or limits one or more major life activities. Severe mental illness includes dementia with delusions, dementia with depressed mood and dementia occurs in conjunction with another diagnosable severe mental illness. The following disorders are included only if they occur in conjunction with another diagnosable mental illness: 1. A substance abuse disorder 2. A developmental disorder 3. A "V" code in the diagnostic and statistical manual of mental disorders. A process designed to help assure that planned services meet medical necessity criteria, and are appropriate to the conditions, needs and desires of the individual. Authorization can occur before services are delivered, at some point during service delivery or can occur after services have been delivered based on a retrospective review. An individual or entity that has an interest, investment or involvement in the operations of a prepaid health plan or affiliate. Stakeholders can include individuals and their families, advocacy organizations, and other members of the community that are affected by the prepaid health plan and the supports and services it offers. Residential facilities, certified by MDICS, to provide intensive mental health service, structured programming, and enhanced supervision to individuals deemed clinically appropriate for this level of care. The individual must have a primary, validated DSMIV (or its successor) diagnosis or a diagnosis of Developmental Disability as defined by the Federal Developmental Disabilities Assistance and Bill of Rights Act. An inpatient program operated by the Michigan Department of Community Health for the treatment of individuals with severe mental illness or serious emotional disturbance. A letter of progress forwarded to the beneficiary for grievance pending resolution beyond 30 calendar days. A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. If the primary diagnosis is mental illness, then the CMH will be the lead agency for the determination of 151 KEY TERMS/PHRASES TERM Substance Use Disorders Technical Advisory Technical Requirement TPL UM Designee UM Plan Urgent Situation Utilization Management “What’s Calendar Coming Wraparound Services WRAP Training Up” DEFINITIONS necessary services, with coordination with the Substance Abuse Coordinating Agency. If the primary diagnosis is substance abuse, then the Substance Abuse Coordinating Agency will be the lead agency for the determination of necessary services, with coordination with the CMH. Substance use disorders include Substance Dependence and Substance Abuse, according to selected specific diagnosis criteria given in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Specific DSM IV diagnoses are found in Attachment 7.0.1.1 of the department's contract with CMHSPs. MDCH – developed document with recommended parameters for PHPs regarding administrative practice and derived from public policy and legal requirements. MDCH/PHP contractual requirements providing parameters for PHPs regarding administrative practice related to specific administrative functions, and derived from public policy and legal requirements. Third Party Liability – refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and worker's compensation) or program (E.g., Medicare) that has liability for all or part of a recipient's covered benefit. Person or entity designated by the Agency to oversee the Utilization Management (UM) Plan. A Plan developed to manage appropriate utilization of services, e.g. frequency, length of services, etc. The Plan must include written policies and procedures to evaluate the appropriateness and effectiveness of Covered Services provided by the MCPN, CA, and subcontractors, and must be approved by the Agency. A situation in which an individual is determined to be at risk of experiencing an emergency situation in the near future if he or she does not receive care, treatment, or support services. Using established criteria to recommend or evaluate the medical necessity of services, effective use of resources, and costeffectiveness. Using established criteria to recommend or evaluate the medical necessity of services, effective use of resources, and cost-effectiveness. A monthly schedule of Consumer activities compiled by the Partnership Initiative group to keep consumers and mental health professionals updated on current events in the Detroit-Wayne CMH area and across the state. The calendar is reviewed on the first Thursday of each month and is distributed by email and hard copy to individuals, providers, consumer organizations and other Agency outreach efforts. Wraparound services are individually designed services provided to minors with SED and their families that include treatment, personal care, or any other supports necessary to maintain child in the family home. Wraparound services are developed through interagency collaboration with the minor's parent or guardian and the minor (if over age 14). The Wellness Recovery Action Plan is a structured system for monitoring mental illness symptoms and through planned 152 KEY TERMS/PHRASES TERM DEFINITIONS responses, reduces, modifies or eliminates those symptoms. Persons may be assisted in this process by supporters and health care professionals of their choice. 153 References 154 References The following references are listed in the Local Appeals for Medicaid Beneficiaries policy: Federal Law 42 CFR: Sections 431.200 et seq., 438.400 et seq. Medicaid Service Provider Manual. Michigan Department of Community Health (Administrative Hearings, Policies and Procedures.) Michigan Mental Health Code, PA 258 of 1974, as amended. Michigan Department of Community Health (MDCH) Managed Care Contract. 155 Appendix I DSM-IV-TR Adult Services 156 DSM-IV ADULT SERVICES MENTAL HEALTH DIAGNOSTIC CODES (290-319) 290 290.12 290.13 290.2 290.20.I 290.21 290.42 290.43 Senile And Presenile Organic Psychotic Conditions Presenile Dementia With Delusional Features Presenile Dementia With Depressive Features Senile Dementia With Delusional Or Depressive Features Senile Dementia With Delusional Features Senile Dementia With Depressive Features Arteriosclerotic Dementia With Delusional Features Arteriosclerotic Dementia With Depressive Features 290.8 290.9 292.84 293 293.81 Other Specified Senile Psychotic Conditions Unspecified Senile Psychotic Condition Drug-Induced Organic Affective Syndrome Transient Organic Psychotic Conditions Organic Delusional Syndrome 293.83 294 294.1 295 295.0 295.1 295.2 295.3 295.4 295.5 295.6 295.7 295.8 295.9 296 296.0 296.1 296.2 Organic Affective Syndrome Other Organic Psychotic Conditions (Chronic) Dementia In Conditions Classified Elsewhere Schizophrenic Disorders Simple Type Disorganized Type Catatonic Type Paranoid Type Acute Schizophrenic Episode Latent Schizophrenia Residual Schizophrenia Schizo-Affective Type Other Specified Types Of Schizophrenia Unspecified Schizophrenia Affective Psychoses Manic Disorder, Single Episode Manic Disorder, Recurrent Episode Major Depressive Disorder, Single Episode 296.3 296.4 Major Depressive Disorder, Recurrent Episode Bipolar Affective Disorder, Manic 296.5 296.6 296.7 296.8 Bipolar Affective Disorder, Depressed Bipolar Affective Disorder, Mixed Bipolar Affective Disorder, Unspecified Manic-Depressive Psychosis, Other And Unspecified 157 296.80 296.81 296.82 296.89 296.9 Manic-Depressive Psychosis, Unspecified Atypical Manic Disorder Atypical Depressive Disorder Other Other And Unspecified Affective Psychoses 296.90 296.99 Unspecified Affective Psychosis Other Specified Affective Psychoses 297 297.0 297.1 Paranoid States (Delusional Disorders) Paranoid State, Simple Paranoia 297.2 297.3 297.8 297.9 298 298.0 298.1 298.2 298.3 298.4 298.8 298.9 300.01 300.14 300.21 300.22 300.3 300.6 Paraphrenia Shared Paranoid Disorder Other Specified Paranoid States Unspecified Paranoid State Other Non-organic Psychoses Depressive Type Psychosis Excitative Type Psychosis Reactive Confusion Acute Paranoid Reaction Psychogenic Paranoid Psychosis Other And Unspecified Reactive Psychosis Unspecified Psychosis Panic Disorder Multiple Personality Agoraphobia With Panic Attacks Agoraphobia Without Mention Of Panic Attacks Obsessive-Compulsive Disorders Depersonalization Syndrome 300.81 301 301.0 301.1 301.10 Somatization Disorder Personality Disorders Paranoid Personality Disorder Affective Personality Disorder Affective Personality Disorder, Unspecified 301.11 301.12 301.13 301.2 301.20 301.22 Chronic Hypomanic Personality Disorder Chronic Depressive Personality Disorder Cyclothymic Disorder Schizoid Personality Disorder Schizoid Personality Disorder, Unspecified Schizotypal Personality 301.3 Explosive Personality Disorder 301.81 Narcissistic Personality 158 301.83 Borderline Personality 307.1 Anorexia Nervosa 307.51 Bulimia 309.81 Prolonged Posttraumatic Stress Disorder 311 Depressive Disorder, Not Elsewhere Classified 312.3 Disorders Of Impulse Control, Not Elsewhere Classified 312.30 Impulse Control Disorder, Unspecified 312.34 Intermittent Explosive Disorder 312.35 Isolated Explosive Disorder 159 Appendix II DSM-IV-TR Children’s Services 160 DSM-IV-TR CHILDREN’S SERVICES MENTAL HEALTH DIAGNOSTIC CODES (290-319) Diagnostic 293 Transient Organic Psychotic Conditions 295 Schizophrenic Disorders 295.0 Simple Type 295.1 Disorganized Type 295.2 Catatonic Type 295.3 Paranoid Type 295.4 Acute Schizophrenic Episode 295.5 Latent Schizophrenia 295.6 Residual Schizophrenia 295.7 Schizo-Affective Type 295.8 Other Specified Types Of Schizophrenia 295.9 Unspecified Schizophrenia 296 Affective Psychoses 296.0 Manic Disorder, Single Episode 296.1 Manic Disorder, Recurrent Episode 296.2 Major Depressive Disorder, Single Episode 296.3 Major Depressive Disorder, Recurrent Episode 296.4 Bipolar Affective Disorder, Manic 296.5 Bipolar Affective Disorder, Depressed 296.6 Bipolar Affective Disorder, Mixed 296.7 Bipolar Affective Disorder, Unspecified 296.8 Manic-Depressive Psychosis, Other And Unspecified 296.80 Manic-Depressive Psychosis, Unspecified 296.81 Atypical Manic Disorder 296.82 Atypical Depressive Disorder 296.89 Other 296.9 Other And Unspecified Affective Psychoses 296.90 Unspecified Affective Psychosis 296.99 Other Specified Affective Psychoses 297 Paranoid States (Delusional Disorders) 161 297.0 Paranoid State, Simple 297.1 Paranoia 297.2 Paraphrenia 297.3 Shared Paranoid Disorder 297.8 Other Specified Paranoid States 297.9 Unspecified Paranoid State 298 Other Non-organic Psychoses 298.0 Depressive Type Psychosis 298.1 Excitative Type Psychosis 298.2 Reactive Confusion 298.3 Acute Paranoid Reaction 298.4 Psychogenic Paranoid Psychosis 298.8 Other And Unspecified Reactive Psychosis 298.9 Unspecified Psychosis 299 Psychoses With Origin Specific Childhood 299.0 Infantile Autism 299.1 Disintegrative Psychosis 299.8 Other Specified Early Childhood Psychoses 299.80 Pervasive Development Disorder 299.9 Unspecified 300 Neurotic Disorders 300.0 Anxiety States 300.00 Anxiety State, Unspecified (Ages 18 And Under Only) 300.01 Panic Disorder 300.02 Generalized Anxiety Disorder 300.1 Hysteria 300.11 Conversion Disorder 300.12 Psychogenic Amnesia 300.13 Psychogenic Fugue 300.14 Multiple Personality 300.2 Phobic Disorders 300.21 Agoraphobia With Panic Attacks 300.22 Agoraphobia Without Mention Of Panic Attacks 300.23 Social Anxiety Disorder (Ages 18 And Under Only) 300.3 Obsessive-Compulsive Disorders 162 300.4 Dysthmia 300.6 Depersonalization Syndrome 300.7 Hypochondriasis 300.81 Somatization Disorder 301 Personality Disorders 301.0 Paranoid Personality Disorder 301.1 Affective Personality Disorder 301.10 Affective Personality Disorder, Unspecified 301.11 Chronic Hypomanic Personality Disorder 301.12 Chronic Depressive Personality Disorder 301.13 Cyclothymic Disorder 301.2 Schizoid Personality Disorder 301.20 Schizoid Personality Disorder, Unspecified 301.22 Schizotypal Personality 301.3 Explosive Personality Disorder 301.81 Narcissistic Personality 301.83 Borderline Personality 302.6 Gender Identity Disorder In Children NOS 307.1 Anorexia Nervosa 307.51 Bulimia 307.6 Enuresis 307.7 Encopresis 309.21 Separation Anxiety Disorder 309.22 Emancipation Disorder Of Adolescence And Early Adult Life 309.81 Prolonged Posttraumatic Stress Disorder 311 Depressive Disorder, Not Elsewhere Classified 312 Disturbance Of Conduct, Not Elsewhere Classified 312.0 Undersocialized Conduct Disorder, Aggressive Type 312.1 Undersocialized Conduct Disorder, Unaggressive Type 312.2 Socialized Conduct Disorder 312.3 Disorders Of Impulse Control, Not Elsewhere Classified 312.30 Impulse Control Disorder, Unspecified 312.34 Intermittent Explosive Disorder 312.35 Isolated Explosive Disorder 312.39 Other 163 312.4 Mixed Disturbance Of Conduct And Emotions 312.8 Other Specified Disturbances Of Conduct, Not Elsewhere Classified 312.81 Conduct Disorder, Childhood Onset Type 312.82 Conduct Disorder, Adolescent Onset Type 312.89 Other Conduct Disorder 312.9 Unspecified Disturbance Of Conduct 313 Disturbance Of Emotions Specific To Childhood And Adolescence 313.0 Overanxious Disorder 313.1 Misery And Unhappiness Disorder 313.2 Sensitivity, Shyness, And Social Withdrawal Disorder 313.23 Elective Mutism 313.8 Other Or Mixed Emotional Disturbances Of Childhood Or Adolescence 313.81 Oppositional Disorder 313.82 Identity Disorder 313.89 Reactive Attachment Disorder Of Infancy Or Early Childhood (Specify Type) 314 Hyperkinetic Syndrome Of Childhood 314.0 Attention Deficit Disorder 314.00 Without Mention Of Hyperactivity 314.01 With Hyperactivity 314.1 Hyperkinesis With Developmental Delay 314.2 Hyperkinetic Conduct Disorder 314.8 Other Specified Manifestations Of Hyperkinetic Syndrome 314.9 Unspecified Hyperkinetic Syndrome 164 Appendix III DSM-IV-TR Developmental Disabilities 165 DSM-IV-TR Developmental Disabilities Diagnostic Codes 317 Mild Mental Retardation 318 Other Specified Mental Retardation 318.0 Moderate Mental Retardation 318.1 Severe Mental Retardation 318.2 Profound Mental Retardation 319 Unspecified Mental Retardation 166 Appendix IV Coordinating Entities 167 The Agency has a variety of coordinating entities and may from time to time modify the following list upon notice to the MCPNs, CAs, and their subcontractors. 1. Medical Health Plans (MHPs) (formerly, “Qualified Health Plans) and their primary care physicians, for the coordination of referrals and services; 2. Primary health care providers for Consumers not involved with MHPs; 3. Children Special Health Care Services (CSHCS) providers; 4. MIChild program, including application for services; 5. Department of Human Services (DHS), including Medicaid applications, Adult and Child Protective Services, Food Stamps, foster care, Women Infants and Children (WIC), and Temporary Assistance to Needy Families (TANF); 6. Department of Consumer and Industry Services, with particular reference to foster care licensing; 7. School districts and any/all special education programs; 8. Early On Program; 9. Health Departments; 10. Michigan Department of Career Development - Rehabilitation Services; 11. Wayne County and Detroit Jobs and Economic Development Departments; 12. Public Housing Commissions; 13. Substance abuse services; 14. OBRA PASARR (Pre-Admission Screening and Annual Review) and Nursing Homes with specialized services; 15. Partnership with multi-purpose collaborative bodies (such as Human Service Coordinating Body); 16. Disability advocacy organizations; 17. EPSDT services; 18. Native American/Tribal Health Services; 19. Jail services/Jail Diversion; 20. Other managed care provider networks serving the DD population; and 21. Any other manager (or provider network) with which the Agency may contract. 168 Appendix V Board of Directors 169 Appendix V: Board of Directors United States Department of Health and Human Services (CMS, SAMHSA) U Un niitteed dS Sttaatteess D Deep paarrttm meen ntt ooff H Hoou ussiin ngg aan nd dU Urrb baan nD Deevveelloop pm meen ntt Michigan Department of Community Health Board of Directors Cindy Dingell, Chairperson George Gaines, Vice-Chairperson Frank Ross, Treasurer John Barden. Janifer Binion, Gary Burtka, , Dorothy Doyley, David Esper, Constance Rowley, Dr. Mouhanad Hammami, Board of Directors Dr. Herbert Smitherman Mohamed Okdie AGENCY AGENCY MCPN Agency Administrative Operations Agency Administrative Consumer Family Advocate Operations Council (CFAC) Consumer Family Advocate Council (CFAC) Management Wayne StateHealth University Behavior Personal Contracts WayneServices State University Other Contracted Vendors Personal Services Contracts Other Contracted Vendors Ethnic (Deloitte & Touche ) Services Providers/SA Coordinating Agencies/MIChild Services Providers/SA Coordinating Alzheimer’s Association, Access, ACC, American Agencies/MIChild Indian Services, Assoc. of Chinese Americans, Latino Ethnic Family Services Services Providers/SA Coordinating Alzheimer’s Association, Access, ACC, American, Direct Care Wage Agencies/MIChild IndianWell Services, of Chinese Americans, Latino Adult Being,Assoc. Arc Down River, Cass Methodist, Care Link Network MCPN Community Living Services Care Link Network MCPN Consumer Link Network Community Living Services Gateway Community Services Ethnic Consumer Link Network Family Services Care Link Network Community Care Services, CLS, LBS, DE, DCI, Synergy Partners Alzheimer’s Association, Access, ACC,STEP, American, Direct Care Wage Hegira, JVS, NC, GC, Wayne Center, SWCDS Gateway Community Services Community Living Services IndianWell Services, Assoc. of Chinese Americans, Latino Adult Being, Arc Down River, Cass Methodist, Catholic Social Services-Respite Person Centered Network Family Services Consumer Link Network Community Care Services, CLS, LBS, Cyprian Early-On Care Wage DCI, FNS, Heggira, JVS, NC, GC, Center,PCC, Ambulatory Services Synergy Partners WEB SITE ADDRESSES Gateway Community ServicesORGANIZATIONS Direct Children’s CeDE, nter, DE, DCI Adult Well Being,STEP, Arc SWCDS Down River, Cass Methodist, Wayne Center, H U D Home &Person Community-Based Services Centered Network Community Care Services, CLS, LBS, Cyprian Catholic Social Services-Respite COTS, CCS, DE, DCI, LBS, Operation Get-Down, www.michigan.gov/mdch Michigan Department of Community HealthJVS, Consultation & Education Center,PCC, DE, DCI, FNS, Heggira, NC, GC, Early -On VNA SWCDS, Ambulatory Synergy ServicesPartners Wayne Center, STEP, SWCDS Consumer Run Services C h i l d r e n ’ s C e n t e r , D E , D C I (Mental Health Jand Substance Abuse) ail Diversion Consultation & Education Hospital-Based Services Consumer Services AmbulatoryRun Services Prevention www.hhs.gov Hospital Based Services Consultation & Education Residential Services Prevention Consumer Run Services Residential Services Hospital Based Services www.hud.gov Prevention Residential Services www.machmhb.org Catholic Social Services-Respite HUDCCS, DCC, NE, WC Prosecutor, WSU-Dept Psychiatry Early O n CCS, DE, Operation Get-Down, MICCOTS, h i l d / L o c k h eedDCI,ELBS, hof ildrenHealth ’s Center, Dand , DCI Human U.S. Department C SWCDS, VNA DCI HUD Jail Diversion Services BlocCOTS, k GraCCS, nts aDE, nd O theLBS, r GrOperation a n ts DCI, Get-Down, CCS, DCC, NE, WC Prosecutor, WSU-Dept Psychiatry DCC, DE, DCI, FNS, LBS, NC, NE, PBPM, Cass MICSWCDS, hild/LocVNA kheed Methodist, C J a i l D iof vIersio n SWCDS, Gand DC U.S. Department Housing Urban WayCCS, ne CDCC, ounNE, ty WC Prosecutor, WSU-Dept Psychiatry Block Grants and Other Grants Development MICC rC ilded Study hliilndic /DE, Lfooc khhe DCC, DCI, FNS, LBS, NC, NE, PBPM, Cass Methodist, Wayne County Probate Court DC I SWCDS, GC Wayne County Senior Services Block Grants and Other Grants Wayne County Michigan Association ofDCI, Community Mental DCC, DE, FNS, LBS, OBRA Clinic for Child Study NC, NE, PBPM, Cass Methodist, Health Boards www.nih.gov Appendix V National CLS, NSO, Wayne Center Wayne County Probate Court Wayne H earingCounty Impaired Sinai/Grace Wayne County Senior Services nin c’sfoW rC drStudy GC, NSO, ChilC drlie ah ivile OBRA Institute Mental Wayne County Probate Court E piof leCp sy tearHealth LS , NC Se On ,W yne Center Wayne County Senior Services M i c h i g a n D e p t C Hearing Impairedareer Development OBRA C AFDAeSaf Options, Sinai/Grace LSa, tN SO, WravyinceeCsenter IC nh foilrC dm reni’o s nWSaeiv er HeaA rFiRn g I m d ayne ep sta NC S, W NS O ,eirrneW D e a f O p t i o n s , S i Epilepsy Center nai/Gver SWCDS, FNS, NSO, SO, MichFiN gSa,nND ept Career Development Epilepsy C CAFAS Information Services ARC Western Wayne 170 Appendix VI Frequently Used Websites 171 Appendix VI: Frequently Used Websites WEB SITE ADDRESSES http://waynecounty.wc/mygo vt/hhs/mhealth or www.dwccmha.com www.michigan.gov/mdch ORGANIZATIONS Detroit-Wayne County Community Mental HealthWayne County Department of Health and Humans Services Michigan Department of Community Health (Mental Health and Substance Abuse) http://www.michigan.gov/mdch/0,1607,7-1322945_5100---,00.html For information and updates to these and other items: -MDCH Appeal and Grievance Resolution Processes Technical Requirement; Local Appeals Resolution Requirements and Process; CMHSP Local Resolution Process MDCH Medical Necessity Criteria; Additional Mental Health Services; Additional Substance Abuse Services MDCH Mental Health and Substance Abuse Services Self-Determination Policy & Practices Guidelines www.hhs.gov For a list of the HCPCS or Revenue Codes, which are updated reqularly: http://www.michigan.gov/documents/costingpercodej wrev7704_140062_7.doc U.S. Department of Health and Human Services www.hud.gov U.S. Department of Housing and Urban Development www.machmhb.org Michigan Association of Community Mental Health Boards www.nih.gov National Institute of Mental Health www.nida.nih.gov National Institute of Drug Abuse www.nccbh.org National Council of Community Behavioral Health Care www.nami.org National Alliance for the Mentally Ill 172 Appendix VII Coordination of Care Glossary 173 Appendix VII: Coordination of Benefits (COB) Glossary The following definitions were developed in the context of administering the Coordinating of Benefits (COB) process. Authorization – A process by which prior-approval is required for specific services before they are provided to the recipient. IMPORTANT NOTE: A MEDICARE BENEFICIARY DOES NOT REQUIRE PRIOR AUTHORIZATION FOR ANY SERVICES. As a result, a beneficiary having both Medicaid and Medicare coverage does not require authorization for services, even if they are necessary under the Medicaid plan. Beneficiary –The individual whose benefits are covered by the carrier. This is the person served by Detroit-Wayne County CMH Agency. Carrier – Any entity that has a responsibility for the financial coverage of health care for a beneficiary. This includes commercial as well as governmental entities. COB – Coordination of Benefits - The process by which multiple carriers are involved in the payment for services provided to a beneficiary. Co-Insurance - A type of patient responsibility for a covered service involving a percentage of a claim. For example, at 20% coinsurance on a $100 claim, requires the beneficiary to pay $20 for the covered service. The beneficiary is not responsible for any co-pays, deductibles or coinsurance fees. Commercial Carrier – A private insurance or Managed Care Organization providing healthcare coverage to a beneficiary. Co-pay – A type of patient responsibility that involves a flat rate that is the responsibility of the beneficiary. For example, a $25 co-pay on prescription drugs means that the beneficiary is responsible for $25 for each prescription drug acquired. The beneficiary is not responsible for any COPA, Deductible or Co-Insurance costs. Deductible – A type of patient responsibility where the patient is responsible for the very first component of care in a period of time such as a year. For example, a beneficiary who has a $500 deductible for inpatient care is responsible for the first $500 dollars in inpatient costs incurred in the benefit year. Deductible can have a complicated nature in that they may be applied to any time frame and sometimes are reset in gaps between occurrences. Medicare beneficiaries have complex structures for inpatient care and need to be specifically reviewed by beneficiary It is important to note that in a COB situation, secondary and other coverages are constructed to cover deductible and other beneficiary out-of-pocket costs. In the case of a Medicaid beneficiary, the patient is held harmless for out of pocket costs. I.E. if at the end of all payments by carriers there remains a patient responsibility, this is to be paid by Medicaid. DEG Download – The process involving the download of Medicaid Enrollment data from the State of Michigan’s “Data Exchange Gateway” 174 EOB – Explanation of Benefit - A term often used interchangeably with EOP. However, an EOB is a document sent to a beneficiary to document a claim payment on their behalf. An EOB is sent by the paying carrier EOP – Explanation of Payment – A term often used interchangeably with EOB. However, an EOP is a document sent to the provider detailing the payment from a carrier. An EOP is sent by the paying carrier. A carrier (including Medicaid) will require that EOPs are received from all other, higher carriers, prior to considering their payment responsibility. Means Testing for Priority Population Beneficiaries – A financial test that is applied to an individual that does not quality for Medicaid to determine what portion of benefits will be covered under the Priority Population segment. There are individuals who have the means to pay all or a portion of their coverage. This test is used to determine this amount. Medicare Crossover – A term used to identify a Medicaid beneficiary that also has Medicare Coverage. Medicare Crossover Claims (or coverage) – This is a commonly used term for a Medicaid beneficiary whose has a claim also covered by Medicare Medicare Part-A – The Hospitalization component of Medicare Coverage. beneficiaries have Medicare Part-A coverage. All Medicare Medicare Part-B – The outpatient clinical component of Medicare Coverage. This coverage is optional to the Medicare beneficiary and must be purchased for a nominal premium. According to the state of Michigan Technical Advisory dated March 18, 1999. A Medicaid plan may purchase this coverage on behalf of the beneficiary. OPL – “Other Party Liability” – For this documents purpose this is another name for COB Out of Pocket Costs – A term used to define the costs that a beneficiary is responsible for, after all carriers have reimbursed the provider. This is limited to items such as co-pays and deductibles, not the difference between a billed amount and a contracted reimbursement level. Patient Responsibility – Any amount that is the responsibility of the beneficiary. Usually involves deductibles and co-pays, but may involve other more complex calculations of benefits. Payor of Last Resort – Medicaid is always the payor of last resort. All other benefits for the covered service must be exhausted prior to Medicaid payment. This definition applies to all Detroit-Wayne consumers . Provider – The entity that has provided the healthcare service to the beneficiary. The provider is looking to the carriers for compensation. They may have to contact and bill more than one carrier to receive payment in full. Primary Coverage – Refers to the carrier that is primarily responsible for the cost of healthcare services provided to a beneficiary. The primary carrier is responsible for payment of care to the extent of their benefit package. Priority Population – The underinsured population that do not qualify for Medicaid enrollment. 175 Remittance Voucher (RV) – A document to support he details of a claim check. interchangeably with an EOP. Also used Scope and Coverage Codes – A classification of a Medicaid beneficiary that determines the level of covered benefits of the individual. COB payment logic is contingent on the Medicaid beneficiary’s Scope and Coverage Code Secondary Coverage – Refers to the carrier that is secondarily responsible for the cost of healthcare services provided to a beneficiary. The secondary carrier is responsible for covering the cost of healthcare services that are left after the beneficiary has exhausted their coverage with the primary carrier. Secondary Carriers typically cover any reduction from the billed charges, including those costs that the patient may be responsible to provide, including deductibles and co-pays. The Secondary Carrier compares the primary payment with their benefits and fee schedule in determining the amount that they will reimburse the provider of care. Spend Down Participant – A category of Medicaid participants that are responsible for a portion of their health care before Medicaid coverage begins. “Third Party Liability – This is also referred to as TPL. For this document’s purpose, TPL is another name for COB. 176 Appendix VIII Performance Standards 177 Appendix VIII: MCPN Performance Standards and Penalties A. Performance Standards and Measures The MCPN is expected to meet specific performance criteria related to key driven policies and service delivery requirements established for the Provider Network (collectively referred to in this Appendix as the "Performance Measures). The Performance Measures are specific contractual requirements and are further delineated below. The Agency may revise this Appendix from time to time, and the MCPN shall comply with the most recent version adopted and distributed. Full compliance with e-form data submission is essential in capturing data for many of these measurement standards. Performance Measures and Corresponding Reporting Requirements: 1. Mental Health Service Delivery: The MCPN shall ensure timely access to Mental Health services. MCPN shall submit monthly reports to the Agency tracking same. The MCPN shall meet the following standards: At least 95% of Consumers receiving a pre-admission screening for psychiatric inpatient care have a complete disposition in three hours. At least 95% of Consumers receive an in-person meeting with a professional within 14 calendar days of a non-emergency request for service (by subpopulation). At least 95% of Consumers start any needed on-going service within 14 calendar days of a non-emergent assessment with a professional (by subpopulation). 2. Inpatient Psychiatric Readmission: The MCPN shall manage Consumers' mental health services in a medically appropriate manner so as to avoid repeated inpatient psychiatric admissions. MCPN shall submit monthly reports to the Agency tracking same. Standard: The percentage of Consumers being readmitted to an inpatient psychiatric setting within thirty (30) days of discharge shall be 15% or less. 3. Psychiatric Inpatient Discharge Follow-Up Care. The MCPN shall ensure that Consumers discharged from a psychiatric inpatient unit are seen for follow-up care within 7 days of discharge. MCPN shall submit monthly reports to the Agency tracking same. Standard: 100% of such Consumers shall be seen within 7 days of discharge. 4. Expenditures on Administrative Functions. The MCPN shall ensure that dollars spent by MCPN on administrative functions is appropriately limited. MCPN shall submit monthly reports to the Agency tracking same. Standard: PMPM amounts attributed towards administrative functions shall not exceed 4.25%. 178 5. Parents of Minor Children. The MCPN shall ensure that it appropriately identifies Consumers who are parents of minor children (ages 0-17), so as to consider their functioning within the parent domain and to include this in the PCP process for such Consumers. Such information shall be included by MCPN in the demographic data submitted to Agency. Standard: 100% of demographic reports shall indicate whether Consumers are parents of minor children, and PCP should reflect attention to same. 6. Early On Program. The MCPN shall ensure that Consumers age 0-3 are enrolled in the Early On program. The MCPN shall track and report same to the Agency through demographic information submitted on a monthly basis. Standard: 100% of Consumers age 0-3 shall be enrolled in the Early On program. 7. Minor Consumers Receipt of Services. The MCPN shall ensure that all Consumers age 0-17 receive more than just respite services, if indicated by individual need assessments. The MCPN shall report to the Agency on children's access to all Covered Services on an annual basis. Standard: MCPN shall track 100% of Consumers age 0-17 and report the array of services provided. 8. Schizophrenia and Anti-Psychotic Medications. The MCPN shall track and report on an annual basis the percentage of adult Consumers, with a diagnosis of schizophrenia receiving an atypical anti-psychotic medication, out of the total number of adult Consumers with schizophrenia served by MCPN. Standard: 100% tracking and reporting is required of MCPN. 9. Anti-Psychotic Medications. The MCPN shall track and report on an annual basis the percentage of adult Consumers, eligible for Medicaid and receiving an atypical antipsychotic medication, out of the number of adult Consumers eligible for Medicaid and receiving any anti-psychotic medication. Standard: 100% tracking and reporting is required of MCPN. 10. Consumers Age 7-17 CAFAS Admission Scores. The MCPN shall track and report on a quarterly basis the percentage of Consumers age 7-17 initiating treatment during the quarter who have admission CAFAS scores, out of the number of Consumers age 7-17 initiating treatment or services during the quarter. Standard: 100% tracking and reporting is required of MCPN. 11. CAFAS Score Tracking. The MCPN shall track and report on a quarterly basis the ratio of Consumers age 7-17 with follow-up CAFAS scores at 90 days post-admission, 180 days postadmission, or at exit, to the number of Consumers age 7-17 with CAFAS scores at admission. Standard: 100% tracking and reporting is required of MCPN. 179 12. Person-Centered Planning Compliance. Person-Centered Planning (PCP) is required for all Consumers and is legally mandated by the Mental Health Code. The MCPN is responsible for and must ensure that each Person has an individually tailored, complete and documented PCP plan, with the exception of Consumers receiving only respite services and/or enrolled solely in the Family Support Subsidy program. The MCPN is also responsible to ensure that each PCP plan complies with MDCH and Agency guidelines. On a quarterly basis, MCPN shall randomly select and present 20 PCP plans to the Agency for review by the Agency or an agent of same, to determine compliance with PCP requirements under the Agreement. Standard: At least 90% of the annual aggregated audited PCP plans shall comply with all PCP requirements. 13. Person-Centered Planning Satisfaction. On a quarterly basis, the MCPN shall survey Consumers regarding Person satisfaction with MCPN's approach to PCP for each Person surveyed, and submit survey summary reports to the Agency. Rating choices are limited to "Poor," "Satisfactory," and "Excellent." Survey responses shall indicate substantial satisfaction with MCPN's PCP process. Standard: At least 90% of the annual aggregated survey responses shall be "Satisfactory" or "Excellent;" of this 90%, at least 50% of responses shall be "Excellent." 14. Self-Determination for Consumers. In order to meet the self-determination outcome criteria for this Agreement, the MCPN must offer Consumers the choice to participate in selfdetermination as a means of achieving Person-designed, directed and controlled Covered Services. The MCPN shall assure that each Person has the opportunity to direct a fixed amount of resources, known as an individual budget, derived from the PCP process. To the extent permitted by Federal, State, and Agency policies, the MCPN shall assist the Person in controlling the resources in his/her individual budget and in determining which Covered Services s/he will purchase, from whom and under what circumstances. In each year of the Agreement, MCPN shall demonstrate through a sufficiently detailed report to the Agency an appropriate increase in the number of Consumers under self-determination models with control of resources. Standard: Person records year-to-year should indicate at least a 15% increase in the number of Consumers under self-determination models with control of resources. 15. Supported Employment For Consumers. The MCPN is required to increase the number of Consumers in supported employment programs, which are defined as at least 10 hours per week of paid employment during the each contract year. The MCPN shall achieve this outcome primarily by assisting Consumers in moving from traditional day programs, work activity centers, and sheltered workshops to supported employment. In each year of the Agreement, MCPN shall demonstrate through a report to the Agency an appropriate number of Consumers in supported employment programs. Standard: Actual wages earned by the MCPN's Consumers must equal 25% of the Total Monthly Potential Wages from Supported Employment by the end of the first year of the Agreement. For each subsequent year of the Agreement, the MCPN shall increase this level by 3%. In each year of the Agreement, the following formula will be applied: the number of Consumers in traditional day programs, work activity programs and/or sheltered 180 workshops multiplied by the aggregate annual number of hours Consumers are involved in such traditional day programs, work activity programs and/or sheltered workshops multiplied by the current Federal minimum wage level divided by 12 months equals the Total Monthly Potential Wages from Support Employment. 16. MCPN Employment of Consumers. In order to facilitate Person input and collaboration for MCPN operations, MCPN shall employ Consumers in a variety of paid positions (to be counted, a position must involve at least 10 hours per week of paid employment), and shall ensure the same from Contracted Providers. In each year of the Agreement, MCPN shall demonstrate through a report to the Agency an appropriate number of MCPN and Contracted Provider employed Consumers. Standard: MCPN and subcontractors shall use best efforts to ensure that at least ten (10%) percent of their employees are in paid positions of at least ten (10) hours per week. 17. Supported Community Living Arrangements For Adult Consumers. Support Community Living means a Person lives independently in his or her own residence in a setting selected by such Person, with the Person holding the lease and choosing who else, if anyone, lives with him/her. MCPN shall submit reports of Consumers in supported living arrangements on a quarterly basis (demonstrating how such arrangement constitutes Supported Community Living), and the Agency will review same and conduct random site visits to Consumers' residences to determine that the requirements of independent living are met. Consumers who stay at the same dwelling will count toward achievement of this standard provided that the name on the lease is changed from another to the Person, and that the Person is living with other individuals selected by the Person. Standard: The MCPN must demonstrate that at least 15% more Consumers age 18 or over are in supported community living arrangements by the end of the first year of the Agreement. The Agency will adopt new standards for subsequent contract years. 18. Family Living Arrangements for Minor Consumers. The MCPN shall facilitate Consumers under the age of 18 living with family members to the extent appropriate in accordance with individually tailored PCP plans. MCPN shall submit monthly reports to the Agency indicating the overall percentage of family living arrangements for Consumers under the age of 18. Standard: The MCPN must demonstrate that at least 15% more Consumers under the age of 18 are living with family members by the end of the first year of the Agreement. The Agency will adopt new standards for subsequent contract years. 19. Covered Services Delivery. The MCPN shall ensure timely access to Covered Services (other than Mental Health and Substance Abuse service delivery, which are further addressed below). MCPN shall submit monthly reports to the Agency tracking same. The MCPN shall meet the following standards: At least 95% of Consumers needing emergency clinical services shall receive same immediately or as soon possible dependent on the situation. At least 95% of Consumers needing urgent clinical care shall receive same within 24 hours of request, including transfer between levels of care during a 181 chemical dependency episode. At least 95% of Consumers needing routine care or services shall receive same within 14 calendar days of Person request or MCPN assessment regarding same. 20. Substance Abuse Service Delivery. The MCPN shall ensure timely access to Substance Abuse services. MCPN shall submit monthly reports to the Agency tracking same. The MCPN shall meet the following standards: At least 95% of Consumers receive an assessment within 24 hours of referral or presentation for urgent situations. At least 95% of Consumers are admitted for treatment within 24 hours of assessment in urgent situations. At least 95% of Consumers receive an assessment for non-urgent situations within five days of referral or presentation. At least 95% of Consumers enter into a treatment program within seven days following a non-urgent assessment. 21. Geographic Access. The MCPN shall ensure geographic access to certain Covered Services, as follows: (i) for office or site-based mental health services, the Person's primary service provider (e.g., case manager, psychiatrist, primary therapist, etc.) must be within 30 miles or 30 minutes of the Person's residence in urban areas, and within 60 miles or 60 minutes in rural areas, and (ii) for office or site-based substance abuse services for Consumers with co-occurring disorders, the Person's primary service provider (e.g., therapist) must be within 30 miles or 30 minutes of the Person's residence in urban areas and within 60 miles or 60 minutes in rural areas. MCPN shall submit monthly reports to the Agency tracking same. Standard: 100% of Consumers shall access mental health and substance abuse service providers as indicated above. 22. MIChild Coordination. The MCPN shall develop and implement criteria to determine Person eligibility for services through MIChild. The MCPN shall ensure a high rate of success in identifying MIChild eligibility. The MCPN shall submit monthly reports to the Agency that identify eligibility criteria and Consumers screened for MIChild eligibility each month. On a quarterly basis, MCPN shall randomly select and present 30 PCP plans for Consumers under age 18 to the Agency, for review by the Agency or an agent of same to determine whether MIChild eligibility screening is indicated to follow up as to whether MCPN has completed such screening with appropriate results. Standard: 95% of Consumers under age 18 eligible for services offered by MIChild shall be so identified by MCPN. 23. Case Management. The MCPN shall ensure appropriate management of Covered Services. To the extent a Person is directed by MCPN to a specific professional for an inperson assessment, the following outcomes should be limited: (i) such assessment results in denial of Covered Services delivery by the professional to the Person, or (ii) such assessment results in the referral of such Person by the professional to another professional for Covered Services. MCPN shall submit monthly reports to the Agency tracking same. 182 Standard: The percent of in-person assessments with professionals that result in service denials, or referrals elsewhere, shall not exceed 20%. 24. Covered Services Denial Appeals. The MCPN shall ensure appropriate denial of Covered Services. MCPN shall submit monthly reports to the Agency tracking same. Standard: The number of Consumers who appeal MCPN denials for any Covered Services and are successful in such appeals shall not exceed 15% of appeals per year. 25. Consumers Rights. The MCPN shall assure cooperation with the Agency’s centralized Office of Recipient Rights. 26. Sentinel Events Management. MCPN shall ensure that Person care is appropriately managed so as to limit Sentinel Events. 27. Sentinel Events Reporting. MCPN shall ensure that all Sentinel Events are appropriately reported to the Agency in accordance with the Agreement. The Agency shall randomly audit 20 Sentinel Event reports per year to determine whether MCPN met all parameters required for each report. Standard: 100% of audited reports shall comply with all requirements. 28. Coordination and Collaboration. The MCPN shall enter into coordination agreements with those entities identified by the Agency, in order to ensure effective service planning and better coordinated Person care. MCPN shall submit quarterly reports to the Agency describing the applicable agreements and scope of collaboration to date. Standard: 100% of those entities listed shall have agreements with the MCPN. 29. Penalties. The MCPN is expected to meet the Performance Measures at all times. The Agency may at its sole discretion subject the MCPN to the following Administrative Sanctions for noncompliance, in addition to or as an alternative to all other rights provided Agency in the Agreement for MCPN breach, including but not limited to those described in Sections 14.4, 14.5 and 18 et seq. of the Agreement. 30. Administrative Watch. If MCPN fails to meet one or more Performance Measure reported on a monthly or quarterly basis, for the applicable month or quarter, the MCPN shall be placed on "Administrative Watch." Administrative Watch means that the Agency shall give highest priority to any MCPN-based complaints or issues related to Consumers, and that the Agency shall require MCPN to provide a corrective action plan for the deficient areas. 31. Administrative Review. If MCPN fails to meet one or more Performance Measure reported on a monthly or quarterly basis, for the second consecutive applicable month or quarter, the MCPN shall be placed on "Administrative Review." Administrative Review means that the Agency shall meet with the MCPN to review specific non-compliant cases and shall work directly with the MCPN to develop a corrective action plan. 32. Administrative Oversight. If MCPN fails to meet one or more Performance Measure reported on a monthly or quarterly basis, for the third consecutive applicable month or quarter, the 183 MCPN shall be placed on "Administrative Oversight." Administrative Oversight means that the Agency will meet with the relevant MCPN staff, employees or Contracted Providers to provide technical assistance and to facilitate improvement of deficient area. 33. Other Sanctions. The Agency shall develop and implement specific noncompliance penalties for some or all of the Performance Measures and MCPN shall be subject to same as they are adopted by the Agency. 184 Appendix IX Benefit Plan Covered Services Grid 185 Service Description HCPCS & Revenue Codes Reporting Code Description from HCPCS& CPT Manuals Medicaid MIChild General Fund (SMI,SED, DD only) ABW Basic *ABW Enhanced Basic Enhanced Adult Child Dev. Disability NOTE: This Agency Benefit Plan grid is to be used in conjunction with the MDCH PIHP/CMHSP Encounter Reporting HCPCS and Revenue Codes. The web address is: www.michiga n.gov/mdch/H IPAAHealth Plan Materials HH Modifiers HH TG Integrated service provided to an individual with co-occurring disorder(MH/S A) SAMSHA Approved Evidenced Based Practices for Co-occurring Disorders: Integrated Dual Disorders Treatment is provided 186 Assertive Community Treatment (ACT) H0039 Assessment Health Psychiatric Evaluation Psychological testing Other assessment Tests T1001, 97802, 97803 90801, 90802 9920199215 9924199275 ACT -Use modifier AM when providing Family PsychoEducation as part of the ACT activities Modifier HE Certified Peer Specialist provided or assisted with a covered service such as (but not limited to) ACT, CLS, skill-building and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered service to a consumer. Not to be used for activities performed by a peer under the coverage “peer delivered.” Nursing or nutrition assessments Psychiatric evaluation Physician evaluation and management Modifier GT: Telemedicine was provided via videoconferencing face-to-face with the beneficiary with 90801,90802 (PE). Physician consultatio ns X X X X X X X X X X X X X X X X X X X X 187 9922199233 96101, 96102, 96103, 96116, 96118, 96119, 96120 96110, 96111, 96105, 90887, H0031 H0002 T1023 Physician services provided in inpatient hospital care (moved from Community Psychiatric Inpatient) Psychological testing X X X X X X X X X X Other assessments, tests (includes inpatient initial review and recertifications, vocational assessments, interpretations of tests to family, etc. Use modifier TS for recertifications) H0031: Assessment by nonphysician Use ST when trauma assessment is performed as part of trauma focused CPT. H0002: Brief screening to non-inpatient programs T1023: Screening for inpatient program X X X X X X X X X X X X 188 Behavior Treatment Plan Review H2000 Clubhouse Psychosocial Rehabilitation Programs H2030 Comprehensiv e multidisciplinar y evaluation, service does not require face-to-face with beneficiary for reporting. Modifier TS activities associated with a behavior treatment plan. However, monitoring of behavior treatment does not need to be face to face with consumer Mental Health Clubhouse Services X X X X 189 Community Living Supports H2015, H2016, H0043, T2036, T2037 H2015comprehensive Community Support Services per 15 min. H2016 – comprehensive Community Support Services per day in specialized residential settings, or for children with SED in a foster care setting that is not a CCI, or children with DD in either foster care or CCI; Use modifiers TG for high need or high cost cases; Use modifier TG for high need or high cost cases; TF for moderate need or moderate need cases; Use in conjunction with Personal Care T1020 for unbundling specialized residential per diem. H0043 – Community Living Supports provided in unlicensed independent living setting or own home, T2036 – therapeutic camping overnight, waiver each session T2037 therapeutic camping day, waiver, each session Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. X 190 Community Psychiatric Inpatient 0100, 0101, 0114, 0124, 0134, 0154 9922199233 Crisis Intervention H2011 H0030, T2034, H2020 Crisis Residential Services H0018 Dental Services (routine) 0100 – All inclusive room and board plus ancillaries 0101 – All inclusive room and board (Use revenue codes for inpatient ancillary services / 0114, 0124, 0134, 0154 – ward size Physician services provided in inpatient hospital care H2011: Crisis Intervention Service H0030: Michigan Center for Positive Living Supports Crisis line (not faceto-face with beneficiary) T2034: Michigan Center for Positive Living Supports Mobile Crisis/Training Team H2020: Michigan Center for Positive Living Supports Transition Home Behavioral health: shortterm residential (non-hosp resident treatment program) without room and board per diem - Use for both child & adult services. Refer to ADA CDT codes X X X X X X X X X X X X X X X X X 191 Electroconvul sive Therapy 90870, 00104 Rev code:0901 Electroconvul sive Therapy 90870, 00104 Rev code:0901 Electroconvul sive Therapy 90870, 00104 Rev code:0901 0901- ECT facility charges 90870attending physician charges 00104anesthesia charges 0701Recovery room 0370anesthesia 0901- ECT facility charges 90870attending physician charges 00104anesthesia charges 0701Recovery room 0370anesthesia 0901- ECT facility charges 90870attending physician charges 00104anesthesia charges 0701Recovery room 0370anesthesia X 192 Enhanced Medical Equipment & Supplies T2028, T2029, S5199, E1399, T2039 Enhanced Pharmacy T1999 E1399 – DME, miscellaneous T2028 – Specialized supply, not otherwise specified T2029 – Specialized medical equipment, not otherwise specified, waiver. S5199 – Personal care item, NOS. T2039- Van lifts & wheelchair tie down system Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in “remarks”. Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. X X X X X X X X 193 Environmental Modifications S5165 Home modifications, per service. Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. X 194 Family Training S5111 S5111- Home care training, family per session S5111 HMParent-toparent support provided by a trained parent using the MDCHendorsed curriculum S5111ST Resource Parent Training by parents as part of Children’s Trauma Initiative when providing TraumaFocused CBT (pre-approved by MDCH). Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. Modifier HA for Parent Management Training Oregon model Modifier HS when beneficiary is not present Modifier TT when multiple consumers are served simultaneously X X 195 S5110, G0177, T1015 Fiscal Intermediary Services T2025 Foster care S5140, S5145 S5110 – Family PsychoEducation: skills workshop G0177 – Family Psychoeducation: family educational groups (either single or multifamily) T1015 – Family PsychoEducation: Note: Please use these codes only when implementing this EBP. Modifier HS: consumer was not present during the activity with the family Financial Management, self-directed, waiver. S5140- Foster care, adult, per diem (use for residential IMD) S5145- Foster care, therapeutic, child, per diem (use for CCI) Licensed settings only. X X X X X X X X X 196 Health Services 97802, 97803, 97804, H0034, S9445, S9446, S9470, T1002 97802-97804 – medical nutrition therapy H0034 Medication training and support S9445 –Pt education NOC nonphysician indiv per session S9446 – Pt education NOC nonphysician group, per session S9470 – Nutritional counseling dietician visit T1002 – RN services up to 15 min X X X X 197 Home Based Services H0036 H2033 Housing Assistance T2038 Intensive Crisis Stabilization S9484 Community psychiatric supportive treatment, face-to-face with child or family, per 15 minutes Modifier HE for Certified Peer Specialist provided or assisted with a covered service such as (but not limited to) ACT, CLS, Skill-building and supported employment. Modifier HA for Parent Management Training Oregon model, Modifier HS when beneficiary is not present Modifier ST when providing Traumafocused Cognitive Behavioral Therapy when pre-approved by MDCH Modifier TT when multiple consumers are served simultaneously face to face Multi-systemic therapy (MST) for juveniles provided in home-based program Community transition, waiver, per service S9484: Crisis intervention mental health services, per hour. Use for the DCHapproved program only. X X X X X X X X X X 198 ICF/MR (Intermediate Care Facility for Individuals with Mental Retardation) Inpatient Psychiatric Hospital State Facility Admissions** 0100 0100 - All inclusive room and board plus ancillaries. X 0100, 0101, 0114, 0124, 0134, 0154 X X X X X Institution for Mental Disease Inpatient Psychiatric Services ** 0100, 0101, 0114, 0124, 0134, 0154 Room & Board Managed State Psychiatric Hospital Inpatient Days - Board Managed State 0100 – All inclusive room and board plus ancillaries 0101 – All inclusive room and board 0114, 0124, 0134, 0154 – ward size 0100 – All inclusive room and board plus ancillaries 0101 – All inclusive room and board 0114, 0124, 0134, 0154 – ward size Refer to HCPCS codes in 80000 range X X X X X X X X X X X Use when provided as a separate service X X X X X X Laboratory Services Related to Mental Health Medication Administration 99605, 99211, 96372 X 199 Medication Review 90862, M0064 90862 brief assessment, dosage adjustment, minimal psychotherapy, TD testing by physician, or physician plus a nurse or nurse practitioner. M0064 brief assessment (generally less than 10 minutes), med monitoring by nurse; med monitoring or change by a nurse practitioner or a physician’s assistant or physician; or PA or MD/DO plus a licensed practical nurse. EPS tardive dyskinesia testing is included in medication review services. Modifier GT: telemedicine was provided via videoconferencing face-to-face with the beneficiary.(90 862) X H2010 Comprehensiv e Medication Services used only with Evidence Based Practice – Medication Algorithm X X X X X X X X X X 200 Nursing Facility Mental Health Monitoring T1017SE Occupational Therapy 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, S8990, 97750, 97755, 97760, 97762 97150 97003, 97004 Out of Home Non Vocational Habilitation H2014HK Use modifier SE to distinguish from case management Modifier SE With T1017 for Nursing Facility Mental Health Monitoring to distinguish from target case management OT individual OT group, per session OT evaluation/reevaluation Skills training and development Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. Modifier TT when multiple consumers are served simultaneously X X X X X X X X 201 Out of Home Prevocational Service T2015 Outpatient Partial Hospitalizatio n 0912, 0913 Habilitation, prevocational, waiver, per hour Modifier HK (specialized mental health programs for high-risk populations) Partial hospitalization X X 202 Peer Directed and Operated Support Services (MH or DD) H0023, H0038, H0046 H0023- Dropin Center attendance, encounter [Note: MUST BE REPORTED ON MUNC] H0038- Mental Health Peer specialist services provided by certified peer specialist, 15 min. H0046 – Peer mentor services provided by a Peer Mentor for Persons with a Developmental Disability Modifier HE Certified Peer Specialist provided or assisted with a covered service such as (but not limited to) ACT, CLS, skill-building and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered service to a consumer. Not to be used for activities performed by a peer under the coverage “peer delivered.” Modifier HF With a Recovery Coach (H0038) when provided as a substance abuse treatment by a peer Modifier HI Peer Mentor provided or assisted with a covered service such as (but not limited to) CLS, skillbuilding and supported employment Modifier TT for H0038 (peer X X X 203 Personal Care in Licensed Specialized Residential Setting** T1020 Personal Emergency Response System (PERS) S5160, S5161 Pharmacy (Drugs & Biologicals) Physical Therapy 97001, 97002 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97760, 97762, S8990 97150 Personal care services provided in AFC certified as Specialized Residential. Use modifier TG for high need or high cost cases; TF for moderate need or moderate need cases; S5160Emergency response system; installation and testing S5161(PERS) Service fee, per month (excludes installation and testing). Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. NDC codes for prescription drugs Line Pharmacy – NCPDP (GF Only Services) PT Evaluation/reevaluation PT individual PT group X X X X X X X X 204 Prevention Services Direct Model H0025 Private Duty Nursing S9123, S9124 Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude, and/or behavior); approved MDCH models only Private duty nursing, Habilitation Supports Waiver (individual nurse only) 21 years and over ONLY Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. Modifier TT – use for multiple beneficiaries in same setting X X X 205 S9123, S9124 Rev code: 0582 T1000 Private duty nursing, Habilitation Supports Waiver (private duty agency only) Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. Modifier TT when multiple consumers are served simultaneously face to face Private duty nursing (Habilitation Supports Waiver) T1000 – private duty/independ ent nursing service(s), licensed Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries Modifier TD – registered nurse Modifier TE – licensed practical nurse or licensed visiting nurse Modifier TT when multiple consumers are served simultaneously face to face X X 206 Residential Room & Board S9976 Respite Care T1005 H0045 S5150 Lodging, per diem, not otherwise specified Respite care services, up to 15 minutes. No modifier = all providers (including unskilled, and Family Friend) except RN & LPN TD modifier = RN only / TE modifier = LPN only Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries Respite care services, day in out-of-home setting Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. Respite care by unskilled person, per 15 minutes (use also for “Family Friend” respite) X X X X X 207 S5151 T2036, T2037 Respite care, day, in-home Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. Respite care at camp T2036: camping overnight (one night = one session) T2037 for day camp (one day/partial day = one session) X X 208 Skill Building Assistance H2014 Skills training and development, per 15 min Modifier TT when multiple consumers are served simultaneously Modifier HE for Certified Peer Specialist provided or assisted with a covered service such as (but not limited to) ACT, CLS, Skill-building and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered service to a consumer. Not to be used for activities performed by a peer under the coverage “peer delivered.” Modifier HI Peer Mentor provided or assisted with a covered service such as (but not limited to) CLS, skillbuilding and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered service to a consumer. Do not to be used for activities performed by a peer under the coverage “peer delivered.” X 209 Speech & Language Therapy 92506, 92610 92507, 92526, 92508 Speech & language evaluation S&L therapy, individual, per session S&L therapy, group, per session X X X X X X X X X X X X 210 Supported Employment Services H2023 Supported employment Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. /Modifier TG for evidencedbased supported employment program that have has at least one fidelity review /Modifier TT when multiple consumers are served simultaneously face to face Modifier HE for Certified Peer Specialist provided or assisted with a covered service such as (but not limited to) ACT, CLS, Skill-building and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered service to a consumer. Not to be used for activities performed by a peer under the coverage “peer delivered.” Modifier HI Peer Mentor provided or assisted with a covered service such as (but not limited to) CLS, skillbuilding and supported employment and only when a certified peer specialist or peer mentor provides or assists with a covered X 211 Supports Coordination T1016 Targeted Case Management T1017 Therapy (mental health) Child & Adult, Individual, Family, Group 90808, 90814, 90815, 90821, 90822, 90828, 90829 90804, 90810, 90811, 90816, 90817, 90823, 90824 T1016 Case management, each 15 minutes. Modifier HK (specialized mental health programs for high-risk populations) must be reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3” Services. Targeted Case management Modifier SE With T1017 for Nursing Facility Mental Health Monitoring to distinguish from target case management Individual therapy, adult or child, 75-80 minutes Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) Individual therapy, adult or child, 20-30 minutes Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) X X X X X X X X X X X X X X X X X X X X X X X X X 212 90806, 90812, 90813, 90818, 90819, 90826, 90827 90853, 90857 90846, 90847 90849 Individual therapy, adult or child, 45-50 minutes Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) Group therapy, adult or child, per session /Modifier HA: Parent Management Training Oregon model Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) Family therapy, per session / Modifier HA: Parent Management Training Oregon model / Modifier HS: consumer was not present during activity with family Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) X X X X X X X X X X X X X X X X X X X X X 213 90805, 90807, 90809 H2019 Individual psychotherapy by a physician when provided as part of a medical visit Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) Therapeutic Behavioral Services: Use for individual Dialectical Behavior Therapy (DBT) provided by staff trained and certified by MDCH. Add TT modifier for group skills training Modifier ST mental health therapy or trauma assessment when providing Trauma Focused CBT (preapproved by MDCH) X X X X X X X X X X X X X X 214 Transportation A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0170, S0209, S0215 T2001T2005 Transportatio n A0427, A0425 Treatment Planning H0032 Wraparound Services (Medicaid Specialty Services and Supports) Wraparound Services (GF) H2021 H2022 [Note: Optional to report on Encounter report] Nonemergency transportation services. Refer to code descriptions. / Do not report transportation as a separate Habilitation Supports Waiver service, or when provided to transport the beneficiary to skill-building, clubhouse, supported employment, or community living activities Non Medicaidfunded ambulance for GF Services ONLY Mental health service plan development by nonphysician / Modifier TS for monitoring treatment plan with consumer present Specialized Wraparound Facilitation Communitybased WrapAround services, per diem X X X X X X X X X X X X X X X X 215 Service Description Substance Abuse: Individual Assessment Substance abuse: Outpatient Care HCPCS Modifier HD Use HD Modifier when recovery Support Services are Provided as part of Women’s Specialty Services (WSS) and Designated Women’s Programs (DWPS) H0001, H0002, H0049 H0001 – Alcohol and/or drug assessment (done by provider) H0002 – Face-to-face behavioral health screening to determine eligibility for admission to treatment program H0049 – AMS Alcohol and/or drug screening for appropriateness for treatment H0004 -Behavioral health counseling and therapy, per 15 minutes 90804-90815 – Psychotherapy (individual) H0004, 90804 – 90815, 90826 Rev Codes: 0900, 0914, 0915, 0916, 0919 H0005, H0015, H0022, H2027, H2035, H2036, H0038, H0050, G0409 Substance abuse: Methadone Substance abuse: Sub-Acute Detoxification T1012, 90846, 90847, 90849, 90853, 90857 Rev codes: 0900, 0914, 0915, 0916, 0919, 0906 H0020 H0010, H0012, H0014 Rev code: 1002 Substance abuse: Residential Services Substance Abuse Reporting Code Description Reporting Code Description from HCPCS& CPT Manuals H0018, H0019 Rev code: 1002 H2034, H0043 H0044 Medicaid & ABW X H0005 – Alcohol and/or drug services; group counseling by a clinician H0015 – Alcohol and/or drug services; intensive outpatient (from 9 to 19 hours of structured programming per week based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education H0022 – Early Intervention services, per encounter H2027- Didactics, per 15 minutes H2035 –SUD treatment program and/or care coordination, per hour H2036 –SUD treatment program and/or care coordination, per diem H0038 HF– Peer services, per 15 minutes, Peer Recovery Coach H0050 – Brief intervention or care coordination per 15 minutes T1012 –Recovery Supports G0409- Recovery and Support Coaching 90826 – Interactive individual psychotherapy 90846 – Family psychotherapy 90847 – Family psychotherapy 90849 - Family psychotherapy 90853 – Group psychotherapy 90857 – Interactive group psychotherapy 0906 – Intensive Outpatient Services – Chemical dependency Alcohol and/or drug services; Methadone administration and/or service (provision of the drug by a licensed program) H0010 – Alcohol and/or drug services; sub-acute detoxification; medically monitored residential detox (ASAM Level III.7.D) H0012 – Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) H0014 - Alcohol and/or drug services; sub-acute detoxification; medically monitored residential detox (ASAM Level I.D) 1002 – Residential treatment – chemical dependency H0018 Alcohol and/or drug services; corresponds to services provided in a ASAM Level III.1 program, previously referred to as short term residential (non-hospital residential treatment program) H0019 Alcohol and/or drug services; corresponds to services provided in ASAM Level III.3 and ASAM Level III.5 programs, previously referred to as long-term residential (non-medical, non-acute care in residential treatment program where stay is typically longer than 30 days) H2034 – Recovery Housing(halfway housing); H0043- 216 Service Description Substance Abuse – Suboxone Early Intervention Group Outpatient Individual Outpatient Laboratory Tests Outpatient (Combination HCPCS H0033 H0022 H0004, 90804 90815, 90826, H2035, H2036, H0050 H0004- Behavioral health counseling and therapy, per 15 minutes. 90804-90815, 90826 – Psychotherapy (individual). H2035- An hour of outpatient alcohol/other drug treatment services. H2036- Per diem outpatient alcohol/other drug treatment services. H0050 - 15 minutes of outpatient alcohol/other drug treatment services (brief intervention) H0003 - Laboratory analysis of specimens to detect presence of alcohol or drugs. H0048 - Alcohol and drug testing, collection and handling only, specimens other than blood. 80100-80101 - Drug Screen. H0015- Alcohol and/or drug services: intensive outpatient (from 9 to 19 hours of structured programming per week based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education. 0906 – Intensive Outpatient Services – Chemical Dependency. H0033 -Oral medication administration, direct observation. (Use for Buprenorphine or Suboxone administration and/or service - provision of the drug). H0020- Alcohol and/or drug services; Methadone administration and/or service (provision of the drug by a licensed program). 99203 - Physician Evaluation/Exam (30 mins face-toface). 99204 - Physician Evaluation/Exam (45 mins face-toface). 99205 - Physician Evaluation/Exam (60 mins face-toface). T1012 - Alcohol and/or drug services; Recovery Support and Skills Development. Activities to develop client community integration and recovery support. H0038 - Peer services, per 15 minutes H0018- Alcohol and/or drug services; short-term H0015 H0033 Pharmacologic Support – Methadone H0020 Physician Evaluation under methadone 9920399205 Residential Treatment H0022 - Alcohol and/or drug services; Intervention Service (Early Intervention). Any planned intervention that may assist a person to abstain for AOD use. H0005- Alcohol and/or drug services; group counseling by a clinician. Family or group therapy 90846, 90847, 90849, 90853, 90857 - Psychotherapy (group). H2027- Didactics - 15 minute units H2035- An hour of outpatient alcohol/other drug treatment services. H2036- Per diem outpatient alcohol/other drug treatment services. H0003, H0048, 80100, 80101 T1012, H0038 H0018, Medicaid & ABW Supported Housing per diem; H0044 – Supported Housing per month Oral medication administration H0005, 90846, 90847, 90849 90853, 90857, H2027, H2035, H2036 Pharmacologic Support – Buprenorphine or Suboxone Recovery Support Services Substance Abuse Reporting Code Description Reporting Code Description from HCPCS& CPT Manuals X X X X X X X X X X 217 Service Description HCPCS H0019 Sub acute Detoxification H0010 , H0012, H0014 Substance Abuse Reporting Code Description Reporting Code Description from HCPCS& CPT Manuals residential (non-hospital residential treatment program). H0019- Alcohol and/or drug services; long-term residential (non-medical, non-acute care in residential treatment program where stay is typically longer than 30 days). 1002 – Residential treatment – chemical dependency. H0010- Alcohol and/or drug services; sub-acute detoxification; medically monitored residential detox (ASAM Level III.7-D). H0012- Alcohol and/or drug services; sub acute detoxification; clinically managed residential detox; nonmedical or social detox setting (ASAM Level III.2-D). H0014 - Alcohol and/or drug services; ambulatory detoxification w/out extended onsite monitoring (ASAM Level I.D). H1002 – Residential treatment – chemical dependency. Medicaid & ABW X 218 Appendix X D-WCCMHA Training Grid 219 Type of Training 1. Corporate Compliance Target Audience All staff Source of Training Employer and VCE Website Note: DWCCMHA staff are required to complete this course on VCE Employer or VCE Website 2. Cultural Diversity/ Competency All staff 3. Emergency Preparedness All staff Employer 4. Health Insurance Portability & Accountability Act (HIPAA) - Basic All staff VCE Website Description of Training Frequency Training on the employer’s Corporate Compliance Plan and information regarding general laws and regulations governing compliance issues in the health care organization New hire. Every two (2) years (biennially) thereafter Training on the employer’s policy, practices, values and expectations for cultural diversity and cultural competence The course will enable staff to identify workplace hazards that could cause an emergency, report emergencies promptly, carry out emergency responsibilities, evacuate quickly and safely and respond to emergency situations effectively This training meets the Michigan Department of Community Health (MDCH) certification requirement for this topic area. This training provides a basic introduction to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. Your employer can and should have policies and procedures that are tailored to its particular functions. You should additionally familiarize yourself with those mandates that are exclusive to your institution. You may select the HIPAA course which best suits your needs and job duties. All members of the D-WCCMHA workforce must complete at least one of the three HIPAA courses biennially (every other calendar year). This training takes approximately 20 to 30 minutes to complete. There are no social work or counseling Continuing Education Credits (CEC) offered with this module. New hire. Every two (2) years (biennially) thereafter New hire. Every two (2) years (biennially) thereafter New hire, Every two (2) years (biennially) thereafter 220 5. Health Insurance Portability & Accountability Act (HIPAA) - Intermediate All staff VCE Website This training meets the Michigan Department of Community Health (MDCH) certification requirement for this topic area. This training provides a basic introduction to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. Your employer can and should have policies and procedures that are tailored to its particular functions. You should additionally familiarize yourself with those mandates that are exclusive to your institution. You may select the HIPAA course which best suits your needs and job duties. All members of the D-WCCMHA workforce must complete at least one of the three HIPAA courses biennially (every other calendar year). This training takes approximately 45 minutes to complete. The course provides 0.5 (1/2 hour) Continuing Education Credits (CEC) offered for licensed social workers and licensed professional counselors for the successful completion of this online course. New hire, Every two (2) years (biennially) thereafter 221 6. Health Insurance Portability & Accountability Act (HIPAA) - Comprehensive All staff VCE Website 7. Limited English Proficiency (LEP)/Language Proficiency All staff Employer or VCE Website Note: DWCCMHA staff are required to complete this course on VCE This training has been updated to reflect the 2011 HIPAA regulation updates and is designed to meet the Michigan Department of Community Health (MDCH) certification requirement for this topic area. This HIPAA compliance training was developed for Wayne County employees who work in the Department of Health and Human Services. As such, it may reference policies and procedures that are unique to Wayne County employees. Your employer can and should have policies and procedures that are tailored to its particular functions. You should additionally familiarize yourself with those mandates that are exclusive to your institution. However, the vast majority of this training is applicable to anyone subject to HIPAA compliance. You may select the HIPAA course which best suits your needs and job duties. All members of the DWCCMHA workforce must complete at least one of the three HIPAA courses biennially (every other calendar year). This training takes approximately 2.5 hours to complete. The course provides 2.5 (2 and 1/2 hour) Continuing Education Credits (CEC) is awarded to licensed social workers and licensed professional counselors for the successful completion of this online course. Procedures for working with individuals with Limited English Language proficiency; training on terminology used in association with the Limited English/language proficiency New hire, Every two (2) years (biennially) thereafter New hire, Every two (2) years (biennially) thereafter 222 8. Medicaid Fair Hearing, Local Appeals and Grievances All Staff VCE Website The course provides an overview of Medicaid Fair Hearing, Local Appeal and Grievance; an overview of the MDCH requirements New hire, Every two (2) years (biennially) Thereafter 9. New Employee Orientation All staff Employer Review of responsibilities, program policies and operating procedures New hire 10. New Hire Recipient Rights All staff Face-to-Face with D-WCCMHA Representative New hire within 30 days 11. Recipient Rights Annual I All staff VCE Website 12. Infection Control & Standard Precautions (Universal Precautions/ Blood Borne Pathogens/Infection Control) All staff VCE Website or Employer Information on RR training for new staff, including confidentiality, abuse and neglect, residential rights and rights complaint process. A Recipient Rights refresher course. It emphasizes four (4) basic rights: Abuse Prevention, Neglect Prevention, Dignity & Respect and Suitable Services. This training provides Information regarding precautions and management of infectious and communicable disease. Information regarding use of Universal Precautions also is explored. Before a temporary license is issued, an applicant and an administrator shall be competent in all of the following areas: (a) Nutrition (b) First aid certification (c) Cardiopulmonary resuscitation (CPR) certification (d) Foster Care, as defined in the act (e) Safety and fire prevention (f) Financial and administrative management (g) Knowledge of the needs of the population to be served (h) Resident rights (i) Prevention and containment of communicable diseases (available at vceonline.org as “Infection Control & Standard Precautions”) 13. Adult Foster Care (AFC) Licensee AFC home owner (includes licensee and designated licensee) Note: DWCCMHA staff are required to complete this course on VCE Employer (using MDCH guidelines or MDCHapproved alternative curriculum) Annual, each calendar year New hire, Every two (2) years (biennially) thereafter Before licensure 223 14. Assertive Community Treatment (ACT) 101 Qualified Mental Health Professionals (QMHP) who work in ACT programs, optional for Clerical Support or Peer Support Specialists Assertive Community Treatment Association (ACTA) 15. ACT Annual Assertive Community Treatment Association (ACTA); Michigan Association of Community Health Boards (MACMHB) 16. ACT for Physicians and Nurse Practitioners Qualified Mental Health Professionals (QMHPs) who work in ACT programs, optional for clerical support, Peer Support Specialists, Physicians and Nurse Practitioners Physicians and Nurse Practitioners who work in ACT programs 17. ACT - Basic Elements of ACT ACT staff who have not completed ACT 101 or Annual ACT training requirements VCE Website Michigan Association of Community Mental Health Boards (MACMHB) This training addresses ACT as an evidencebased practice, the history of ACT, ACT dissemination in the US, MH recovery and community living in ACT, recovery and empowerment, principles of the ACT model, the targeted population, client profiles and treatment components, the services provided in ACT, ACT team composition, ACT program standards and guidelines, and outcome measures in ACT. Various courses and topics related to ACT offered by ACTA or MACMHB. New Hire; one time within six (6) months of hire This is an introductory course specifically for Psychiatrists and Nurse Practitioners providing Assertive Community Treatment. Topics include: history, practice, principles, and philosophy of recovery and benefits of ACT. Physicians and nurse practitioners may take either ACT 101 or this course. This is a Substance Abuse and Mental Health Services Administration (SAMHSA) introductory course for Assertive Community Treatment practitioners. Topics covered include: history, practice principles, philosophy of recovery and benefits of ACT. New Hire; one time within six (6) months of hire Annual Preferred for ACT staff, but not required 224 18. ACT Advanced Elements I: Recovery and the StressVulnerability Model ACT staff who have not completed ACT 101 or Annual ACT training requirements VCE Website This is a SAMHSA advanced course on the theoretical model for ACT, an evidence-based practice. The course provides specific information about the Recovery and the Stress Vulnerability Model. Preferred for ACT staff, but not required 19. ACT Advanced Elements II: Core Processes of Assertive Community Treatment VCE Website This is a SAMHSA advanced course on the core processes of ACT. Preferred for ACT staff, but not required 20. ACT Advanced Elements III: Service Areas of Assertive Community Treatment ACT staff who have not completed ACT 101 or Annual ACT training requirements ACT staff who have not completed ACT 101 or Annual ACT training requirements VCE Website This is a SAMHSA advanced course on the service areas of ACT. Preferred for ACT staff, but not required 21. The ACT Field Guide VCE Website This is a SAMHSA course based on the ACT Field Guide Preferred for ACT staff, but not required 22. Applied Intervention Skills Training (ASIST) ACT staff who have not completed ACT 101 or Annual ACT training requirements First responders and front line staff VCE Live Event This is a two-day, interactive workshop that provides practical training for caregivers seeking to prevent the immediate risk of suicide. Its emphasis is on suicide first aid, helping an individual who is at-risk stay safe and seek further help. Techniques to evaluate for potential suicide risk and provide interventions for responding to such risk are addressed. Preferred, but not required 225 23. Assessing and Managing Suicide Risk (AMSR) Qualified Mental Health Professional (QMHP), Qualified Mental Retardation Professional, (QMRP), Child Mental Health Professional (CMHP) and clinical staff working in the Wayne County Access Center All personnel responsible for billing and coding VCE Live Event This is a one-day workshop providing information for clinicians on assessing and managing suicide risk. Preferred, but not required 24. Billing & Coding Employer Information/updates of billing and coding requirements/procedures for billing staff. New hire, Every two (2) years (biennially) thereafter 25. Child & Adolescent Functional Assessment Scale (CAFAS) Child Mental Health Professional (CMHP) providing direct clinical services to adolescents ages 7 through 17 Employer New hire, Every two (2) years (biennially) thereafter 26. Case Management /Supports Coordination All Case Managers and Support Coordinators Employer 27. Children’s Diagnostic and Treatment Services Programs Specific Training for CMHPs Child Mental Health Professionals (CMHPs) VCE Live Events Other Community Resources Self Study Employer Training on the CAFAS subscales including an understanding of reliability and validity. Individuals will be trained on how to administer and score the subscales in order to accurately rate the individuals we serve and monitor progress in treatment. At the completion of the training, staff will complete selftraining vignettes to establish reliability. Information related to the core requirements (assessment, planning, advocacy, monitoring and linking) and applicable to the target population served. Training on working with children and adolescents ages birth to 18. For further information see the Michigan Department of Community Health Training Requirements for Child Mental Health Professionals presented by the Detroit-Wayne County Community Mental Health Agency Training Requirements for Child Mental Health Professionals. New hire, Every two (2) years (biennially) thereafter Annual – 24 hours each calendar year 226 28. Cardio-Pulmonary Resuscitation (CPR) 29. Co-Occurring Disorders 30. Customer Service Introduction to Access System 31. Customer Service Access Staff 32. Devereux Early Childhood Assessment for Infants (DECA-I) Key staff as identified by Employer. Includes Direct Care Workers who provide Community Living Supports (CLS) or respite services. Qualified Mental Health Professional (QMHP), Qualified Mental Retardation Professional, (QMRP), Child Mental Health Professional (CMHP) and clinical staff working in the Wayne County Access Center Employer Customer Service Staff from: DWCCMHA, Access Center, MCPN and, Service Providers Customer Service Access Staff D-WCCMHA /Pioneer Behavioral Health Child Mental Health Professional (CMHP) providing services to infants ages birth to 18 months MDCH VCE Live Events VCE Website Self Study Employer Other Community Resources D-WCCMHA /Pioneer Behavioral Health This training focuses on Cardiopulmonary Resuscitation, Rescue and basic life support techniques. It also discusses the purpose and use of Automated External Defibrillator (AED). New hire as determined by Employer. VCE offers a quarterly Systems Transformation Learning Series addressing co-occurring issues. This series has been videotaped since 2008 and the presentations are available for viewing on the VCE website, along with videos from Change Agent trainings by Kenneth Minkoff, MD and Christie Cline, MD. To locate these video presentations at www.vceonline.org, click the System Transformation sub-tab of the Training Videos tab under Training. All Customer Service staff must attend to become familiar with the systemwide changes to the role and responsibility of Agency’s Customer Service and that of the New Access System. Every two (2) years (biennially) All Access Customer Service staff must attend to become familiar with Customer Service standards, service array, information and referral, policies and procedures and mandated reporting. Training on the use of the standardized DECA-I assessment tool. New hire, annually thereafter Current card required. One time One time 227 33. Devereux Early Childhood Assessment for Toddlers (DECA-T) 34. Family Psycho Education (FPE) 35. First Aid 36. Infant Mental Health (Endorsement) Child Mental Health Professional (CMHP) providing direct service to toddlers ages 18-36 months Qualified Mental Health Professional (QMHP) and Child Mental Health Professional (CMHP) providing services to consumers Direct Care Workers who provide Community Living Supports (CLS)/respite services MDCH Training on the use of the standardized DECA-T assessment tool. One time MDCH EMU Minimum of 2.7 days of training and 1.5 hours of supervision monthly. Training content focuses on the bio-psychosocial models three (3) components: joining, family skills workshop and problem solving groups. One-time training; ongoing supervision Employer New hire. Current card required. Child Mental Health Professional (CMHP) who work with children birth to age 47 months; all Infant Mental Health clinicians and supervisors Michigan Association for Infant Mental Health (MI-AIMH) A course regarding emergency preparedness/First Aid. It addresses the basic principles of first aid and knowing how and when to put this knowledge to the best use. and child including basic care for bleeding, burns Minimum of 30 clock hours of relationship-based education and training pertaining to the promotion of social emotional development and/or practice of infant mental health. Applicants will include as many hours as necessary to document that competencies (as specified in Competencies Guidelines) have been met. Please see Appendix D for requirements for maintaining and advancing through Endorsement levels. 228 37. Integrated Dual Diagnosis Treatment (IDDT) 38. Medication 39. New Employee Orientation 40. Preschool and Early Childhood Functional Assessment Scale (PECFAS) Child Mental Health Professional (CMHP), Qualified Mental Health Professional (QMHP), and Qualified Mental Retardation Professional (QMRP) providing services to people with Serious Mental Illness (SMI) with cooccurring with Substance Use Disorder (SUD) in IDDT programs Staff administering and dispensing medications (excluding LPNs, RNs, PAs, MDs, DOs, NPs) All staff Child Mental Health Professional (CMHP) providing direct services to children with Severe Emotional Disorder (SED), ages 3 through 7 EMU Other Community Resources Employer VCE Live Event This training focuses on recognizing, assessing, diagnosing and treating severe mental health conditions co-occurring with SUD. It may include: Stage-Wise Assessment and treatment planning Stage-Wise Interventions Pharmacological supports Motivational Interviewing and interventions Children with SED and cooccurring SUD New hire Employer for New Hires, VCE Website offers “Medication Administration Refresher” which can be taken to meet the biennial refresher requirement, which cannot take the place of the initial Face to Face requirement for New Hires Employer This course addresses appropriate medication administration and common mistakes made during the administration of medication in various settings. New hire, Every two (2) years (biennially) thereafter Review of responsibilities, program policies and operating procedures. Two-day training on the PECFAS subscales, including an understanding of reliability and validity; individuals will be trained on how to administer and score the subscales in order to accurately rate the individuals we serve and monitor progress in treatment. At the completion of the training, staff will complete selftraining vignettes to establish reliability. New hire VCE Live Event N/A 229 41. Person-Centered Planning All Staff 42. Parent Management Training – Oregon model ® (PMTO) Child Mental Health Professional (CMHP) working in the PMTO evidencebased practice VCE Website PMTO certified trainers This course provides a brief overview of the philosophy and methods of person-centered planning and familycentered practices is. It also offers instruction on conducting person center planning meetings. Each CMHP who provides PMTO must be in the process or have completed the PMTO certification requirements. PMTO is an evidencebased structured intervention program to help parents and caregivers manage the behavior of children. It is designed to promote social skills and cooperation and prevent, reduce and reverse the development of moderate to severe conduct problems in children age 4 - 12. New hire, Every two (2) years (biennially) thereafter N/A 230 43. Providing Residential Services in Community Settings Direct Care Staff in AFC homes; Specialized Residential homes and Child-Caring Institutions Employer (using MDCH guidelines or MDCHapproved alternative curriculum) 44. Trauma-Focused Cognitive Behavioral Therapy (TF/CBT) Child Mental Health Professional (CMHP) working in organizations participating in the MDCH TF/CBT Project MDCH (a) Nutrition (b) First aid certification (c) Cardiopulmonary resuscitation certification (d) Safety and fire prevention/emergency preparedness (e) Knowledge of the needs of the population to be served (f) Resident rights (The Rights of Individuals Receiving Mental Health Services) (g) Prevention and containment of communicable (available at VCE Online as “Infection Control & Standard Precautions”) (h) Health, Safety & Wellness/Other Med Care (i) Medications (if pass meds) (j) Introduction to Community Residential Services (k) Working with People: Introduction to Human Needs, Values, Guiding Principles, & Effective Teaching Strategies (l) Working with People: Positive Techniques to address Challenging Behavior (m) Plus any extra individual PCP/Assessment Plan needs MDCH 12-month training for masters-prepared Child Mental Health Professionals to become certified Trauma-Focused CBT practitioners. Training includes pre-training, coaching calls, evaluation and supervision. Once certified, the TraumaFocused CBT practitioners can use the ST modifier for home-based services. New hire: Note that when leaving the field and returning after a 3 year absence, this training must be repeated. Prior to providing TF/CBT as an encounterable service 231 45. Wraparound Orientation All Wraparound staff MDCH 46. Wraparound Annual All Wraparound staff VCE Live Event MDCH three (3) day wraparound orientation. Wraparound is based on a model of service that develops plans focusing on the individual strengths and needs of members of the family. The approach generally involves establishing a team that develops a strategic, individualized plan for meeting individual and family needs through a variety of resources. Advance training in the Wraparound model. New hire (one time only) Supervisorsannually, Staff-quarterly 232 Appendix XI: Forms Notice of Rights of Wayne County Residents 233 Notice of Rights for Wayne County Residents When Denied CMH Services Wayne County residents who are applicants for or recipients of public mental health services have the right to a fair and efficient process for resolving complaints including those regarding the denial, reduction or termination of services and supports which they request that are managed and/or delivered by Agency service programs and the Service Provider network. If you are an applicant for hospital admission and you are denied authorization for inpatient treatment by the psychiatrist after a face to face assessment, you have the right to a second opinion. A second opinion is another review of your clinical situation by a different psychiatrist from the one who made the denial, and may require further contact with you. To request a second opinion, you must: -Do so within two (2) days of being told of the denial; -Do so by contacting the director of the screening center or Children’s Central Screening service, if applicant is a minor, where you were assessed, either in person or by completing and submitting the Agency request form. (See Attached Request Form) within the allowed 2 days. The second opinion will be completed within three (3) business days after your request is received by the Service Provider director. If the second opinion is different from the first one, the Service Provider director or designee in consultation with the medical director will determine whether or hospitalization will be authorized. Within one (1) business day you will be notified of the decision verbally, followed by documentation in writing. If your request for a second opinion is timely and appropriate but is refused, or the response is unduly delayed, you or someone acting in your behalf may make a complaint to the Office of Recipient Rights. You may do so by calling (888) 339-5595 and TDY (800) 630-1044. If the second opinion agrees with the first one, and the initial denial is upheld, but you still dispute the conclusion, you may make a complaint to the Office of Recipient Rights. You may do so by calling (888) 339-5595 and TDY (800) 630-1044. If you are currently receiving other Agency services/supports, and the initial request for hospitalization is denied, you, or someone on your behalf may file a recipient rights complaint alleging a violation of the right to treatment suited to condition. If you are not currently receiving any CMH services/supports, and have applied for and been denied all services and have been referred outside the CMH network after a face to face assessment, you have the right to a second opinion. The second opinion involves a repeat review of your clinical situation .by a different psychiatrist from the one who gave the initial adverse decision. 234 To request a second opinion, you must -Do so within two (2) days of being informed of the adverse decision, -Do so by contacting the director of the screening center or, in the case of a minor, the Children’s Screening Center where the initial assessment was done, either in person or by completing and submitting the necessary information of the Agency request form (See Attached Request Form) within the 2 days. The second opinion request must be resolved within five (5) business days after your request is received by the Service Provider director/designee. If the second opinion differs from the initial one, the director designee of the Service Provider, may direct services. If the second opinion is the same as the first, a referral outside the Agency network will be offered. If the request for a second opinion is denied or unduly delayed, you may file a rights complaint with the Office of Recipient Rights, by calling (888) 339-5595 and TDY (800) 630-1044. 235 Request for Second Opinion on Denial of Denial of Admission to Agency Services APPLICANT INFORMATION STATE SERVICE DENIED: Inpatient Treatment Other/All Services: (Check One) Applicant M/F NAME: Last, DOB First, Middle Init. (Circle one) SS# Insurance Status: None or Medicaid: Medicaid ID # (Circle ) Preadmission Review Denial Date: Name of Screening Center or Children’s Screening Service: Denied By: Denial Date: PRINT NAME OF PSYCHIATRIST State Basis for Disagreement With Denial Decision: Requested by Phone and Fax #’s (If Other Than Applicant. State Name and Relationship) Signature: Of APPLICANT or REQUESTING PERSON Date and Time INFORMATION FROM THE SERVICE PROVIDER DATES: REQUEST RECEIVED APPROVED: DECISION MADE DENIAL UPHELD APPLICANT NOTIFIED REFERRAL RATIONALE Signature of Director or Designee: 236 <Service Provider Name> <Service Provider Address> <Address Continued> Medicaid Beneficiaries INDIVIDUALIZED PLAN OF SERVICE (IPOS) Adequate Notice of Action for Medicaid Fair Hearing and Local Appeal Rights Attention: Medicaid ID#: Date:_______ Consumer/Guardian Name and Address: This Adequate Notice of Action for Medicaid Beneficiaries is being given to you following your recent Individualized Plan of Service (IPOS) development, amendment or periodic review. Your IPOS amendment and periodic reviews define the amount, scope, duration and commencement date for services and supports. Services will start within 14 calendar days from the agreed upon start date. ACTION EFFECTIVE ON: ____________________________ Legal Basis for the above decision is 42CFR440.230(d) If you do not agree with your plan or the action taken by your Service Provider, you can ask for an Appeal. A Local Appeal is a review of the Action by someone who was not part of the decision-making that led to the action you are appealing; and who has the skills needed to review the action. The two types of Appeals are described below. You can request a Local Appeal and a Medicaid Fair Hearing at the same time or separately. Medicaid Fair Hearings You have up to 90 (calendar) days from the date on the Notice of Action to ask for a Medicaid Fair Hearing. To request a Medicaid Fair Hearing fill out the “Request for Hearing” form that came with this Notice of Action and mail it in the pre-paid envelope provided. You can also mail it yourself to: Administrative Tribunal Department of Community Health P.O. Box 30763 Lansing, MI 48909-7695 If you have any questions you can contact the Administrative Tribunal directly at: 1-877-833-0870 You can choose to have another person represent you at the Medicaid Fair Hearing. If you do want someone else to represent you then you have to give that person permission in writing. On the “Request for Hearing” form you will have to fill out Sections 2 and 3. The person you choose to represent you can be anyone you choose as long as: o He/she is at least 18 years old; o You have given them written permission on the “Request for Hearing” form by checking YES in Section 2 and having the person who is representing you fill out Section 3. *You will still need to fill out and sign Section 1; o Your guardian or conservator can represent you IF a copy of the Court Order naming the guardian/conservator is sent with the “Request for Hearing” to the Administrative Tribunal. If you ask for a Medicaid Fair Hearing within 12 (calendar) days from the date of the Notice of Action; or if your services were reduced, terminated or suspended without advance Notice of Action, the Service Provider has to reinstate services until an Administrative Law Judge makes a decision. If you have continued to receive services, while the decision was being made, and the Administrative Law Judge decides the Service Provider decision was correct, you might be responsible for the cost of the services that were provided during that time. 237 You can contact your Service Provider to help you with reviewing your case file before and while the Medicaid Fair Hearing is pending to look for things that will support your case. You will be able to present information in person and/or writing prior to and during the Medicaid Fair Hearing before a decision is made. You can request a faster hearing if waiting would put your ability to reach, keep, or get back to your maximum functioning level seriously at risk. To ask for a faster Medicaid Fair Hearing you must call 1-877-833-0870. Local Appeal You have up to 45 (calendar) days from the date of the Notice to ask for a Local Appeal. You can ask for a Local Appeal in two ways. o Fill out the “Request for Local Appeal” form that came with this Notice of Action and give it to your Service Provider who will send you a letter saying they received your “Request for Local Appeal” and that they are sending the Local Appeal to the Appeals Coordinator at Detroit-Wayne County Community Mental Health Agency (D-WCCMHA) for review and a decision. o You can call your Service Provider tell them that you want to file a Local Appeal. They will fill out the “Request for a Local Appeal” form for you and then send it to D-WCCMHA for review and a decision. If you have questions or need help filing a Local Appeal you can contact your Service Provider and/or the DWCCMHA Customer Services at 313-833-3232/TDY 800-630-1044. You can contact your Service Provider to help you with reviewing your case file before and during the Local Appeal to look for things that will support your case. You will be able to present information in person and/or writing to the Appeals Coordinator before a decision is made. You can choose to have someone help you with your Local Appeal. You can also choose to have someone represent you during the Local Appeal. If you ask for a Local Appeal within 12 (calendar) days from the date of the Notice; or if your services were reduced, terminated or suspended without advance Notice of Action, the Service Provider has to reinstate services until the Appeals Coordinator makes a decision. You can ask for a faster Local Appeal if waiting would put your ability to reach, keep, or get back to your maximum functioning level seriously at risk. To ask for a faster Local Appeal tell your Service Provider that you need one. Contact your Service Provider with questions and to file Local Appeals <Service Provider Name> <Service Provider Address> <Service Provider Phone> <Service Provider Fax> <Service Provider TDY> MY SIGNATURE INDICATES THAT I HAVE BEEN GIVEN INFORMATION ON MY RIGHT TO A LOCAL APPEAL and MEDICAID FAIR HEARING. Beneficiary Name: Notice Date: (Print Name of Person Receiving Service) Beneficiary’s Birth Date: Social Security #: Signature Date: (Beneficiary’s signature or Beneficiary’s Authorized Representative’s) Beneficiary’s Authorized Representative’s Name: Phone Number: Print Staff Name: 238 Title/Credentials: Staff Signature: Date: Enclosed: Request for Hearing Form/Envelope and Request for Local Appeal Form Document: Given to: <Consumer Name> Medicaid Fair Hearing Form/Envelope Date: Request for Local Appeal Form Date: Date Received: By: Notice of Action Date copied for record: 239 (INSERT SERVICE PROVIDER LETTERHEAD) <Name of Service Provider> <address> <phone/fax> Advance Action Notice Date Name Address City, State, Zip RE: Beneficiary’s Name: Medicaid ID #: Following a review of the mental health services and supports you are currently receiving, it has been determined that the following service(s) shall be <reduced, terminated or suspended> effective <date>. Service(s) Effective Date ______________________________________________ ______________________________________________ __________________ __________________ The reason for this action is <reason>. The legal basis for this decision is 42 CFR 440.230(d). If you do not agree with this action, you may request a local appeal or a Medicaid Fair Hearing, either orally or in writing, with within 45 calendar days of the date of this notice by contacting your service provider listed above. You have a right to an expedited local appeal if waiting for the standard time for a local appeal would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited local appeal, you must call your service provider and can ask for <insert name of individual responsible for local appeal process>. You will continue to receive the affected services until the local appeal decision is rendered if your request for an appeal is received prior to the effective date of action. If you continue to receive benefits because you requested an appeal you may be required to repay the benefits. This may occur if: The proposed termination or denial of benefits is upheld in the hearing decision. You withdraw your hearing request. You or the person you asked to represent you does not attend the hearing. If you do not agree with this action, you may also request a Michigan Department of Community Health fair hearing within 90 calendar days of the date of this notice. Hearing requests must be made in writing and signed by you or an authorized person. To request a fair hearing, complete the “Request for Hearing” form, and mail to: ADMINISTRATIVE TRIBUNAL MICHIGAN DEPARTMENT OF COMMUNITY HEALTH P.O. BOX 30763 LANSING, MI 48909-7695 You have a right to an expedited hearing if waiting for the standard time for a hearing would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited hearing, you must call, toll-free, 877-833-0870. 240 You may request both a fair hearing and a local appeal. The fair hearing and local appeal processes may occur at the same time. You may contact your service provider if you have further questions. Enclosures: Local Appeal Request Form & Hearing Request Form 241 (INSERT SERVICE PROVIDER LETTERHEAD) <Name of Service Provider> <address> <phone/fax> Adequate Action Notice Date Name Address City, State, Zip RE: Beneficiary’s Name: Medicaid ID #: Following a review of the mental health services for which you have applied, it has been determined that the following service(s) shall not be authorized. Service(s) __________________________________________ __________________________________________ Effective Date __________________ __________________ The reason for this action is <reason>. The legal basis for this decision is 42 CFR 440.230(d). If you do not agree with this action, you may request a Local Appeal or a Medicaid Fair Hearing, either orally or in writing, with within 45 calendar days of the date of this notice by contacting your service provider listed above. You have a right to an expedited local appeal if waiting for the standard time for a local appeal would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited local appeal, you must call your service provider and can ask for <insert name of individual responsible for local appeal process>. If you do not agree with this action, you may also request a Michigan Department of Community Health fair hearing within 90 calendar days of the date of this notice. Hearing requests must be made in writing and signed by you or an authorized person. To request a fair hearing, complete the “Request for Hearing” form, and mail to: ADMINISTRATIVE TRIBUNAL MICHIGAN DEPARTMENT OF COMMUNITY HEALTH P.O. BOX 30763 LANSING, MI 48909-7695 You have a right to an expedited hearing if waiting for the standard time for a hearing would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited hearing, you must call toll-free, 877-833-0870. You may request both a fair hearing and a local appeal. The fair hearing and local appeal processes may occur at the same time. You may contact your service provider if you have further questions. Enclosures: Local Appeal Request Form & Hearing Request Form 242 Local Appeal Request Form M Written Request Oral Request Name of the Service Provider Address City State Phone# Fax# ZIP Code SECTION 1: To be completed by the person requesting a local appeal Your Name Your Home Telephone# Your Address (No. & Street, Apt#, etc.) City State ZIP Code Work or Cell Telephone# Date of Birth: Social Security #: Your Signature Date Signed What Agency took the action or made the decision you are appealing: Local Appeal Request for Standard Resolution Resolution Expedited I WANT TO REQUEST A LOCAL APPEAL: The following are my reasons for requesting a local appeal. Use Additional Sheets if Needed. I would like an opportunity to look at my case file/medical that will be considered during the appeal process? □Yes □ NO I would like an opportunity to present information for review/ consideration during the appeal process? □ Yes □ NO SECTION 2: Have you chosen someone to assist or represent you with this request? Has someone Agreed to Represent you in this local appeal? Name of Representative: _____ YES (If Yes, fill-in information below) Representative Telephone# ____ NO Work/Cell # 243 Address (No. & Street, Apt#, etc.) Representative Signature Date Signed 244 Request for Hearing Instructions OVERVIEW You may use this form to request a hearing. You may also submit your hearing request in writing on any paper. A hearing is an impartial review of a decision made by the Michigan Department of Community Health or one of its contract agencies that client believes is wrong. GENERAL INSTRUCTIONS: Read ALL instructions FIRST, then remove this instruction sheet before completing the form. Complete Section 1. Complete Section 2 only if you want someone to represent you at the hearing. Do NOT complete Section 4. Please use a PEN and PRINT FIRMLY. If you have any questions, please call toll free: 1 (877) 833 - 0870. Remove the BOTTOM (Yellow) copy and save with the instruction sheet for your records. After you complete this form, mail it to: Michigan Administrative Hearing System FOR THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH PO BOX 30763 LANSING MI 48909 You may choose to have another person represent you at a hearing. This person can be anyone you choose but he/she must be at least 18 years of age. You MUST give this person written permission to represent you. You may give written permission by checking YES in SECTION 2 and having the person who is representing you complete SECTION 3. You MUST still complete and sign SECTION 1. Your guardian or conservator may represent you. A copy of the Court Order naming the guardian/conservator must be included with this request. The Department of Community Health will not discriminate against any individual or group because of race, sex, religion, age, national origin, marital status, political beliefs or disability. If you need help with reading, writing, or hearing, you are invited to make your needs known to the Department of Community Health. If you do not understand this, call the Department of Community Health at (877) 833-0870. Si Ud. no entiende esto, llame a la oficina del Departamento de Salud 1 (877) 833 - 0870 Comunitaria. Completion: Is Voluntary DCH-0092 (SOAHR) INSTRUCTION SHEET (Rev. 3-06) See the Request Form Underneath 245 Request for Hearing Form Michigan Administrative Hearing System FOR THE DEPARTMENT OF COMMUNITY HEALTH PO BOX 30763 LANSING, MI 48909 1-877-833-0870 SECTION 1 – To be completed by PERSON REQUESTING A HEARING: Your Name Your Telephone Number ( ) Your Signature Your Address (No. & Street, Apt. No.) City State ZIP Code What Agency took the action or made the decision that you are appealing. Your Social Security Number Date Sign ed Case Number I WANT TO REQUEST A HEARING: The following are my reasons for requesting a hearing. Use Additional Sheets if Needed. Do you have physical or other conditions requiring special arrangements for you to attend or participate in a hearing? NO YES (Please Explain in Here): SECTION 2 – Have you chosen someone to represent you at the hearing? Has someone agreed to represent you at a hearing? NO YES (If YES, have the individual complete section 3) SECTION 3 – Authorized Hearing Representative Information: Name of Representative Representative Telephone Number ( ) Address (No. & Street, Apt. No.) Representative Signature Date Signed City State ZIP Code SECTION 4 – To be completed by the AGENCY distributing this form to the client Name of Agency AGENCY Contact Person Name AGENCY Address (No. & Street, Apt. No.) City State ZIP Code AGENCY Telephone Number ( ) State Program or Service being provided to this appellant DCH-0092 (SOAHR) (Rev 3/06) DISTRIBUTION: WHITE (2nd page) Administrative Tribunal, YELLOW - Person Requesting Hearing 246 ADMINISTRATIVE TRIBUNAL FORMS REQUISITION STATE OFFICE OF ADMINISTRATIVE HEARINGS AND RULES INSTRUCTIONS FOR THE DEPARTMENT OF COMMUNITY HEALTH Order only the forms listed below on this requisition. All other items will be deleted. Specify the quantity you NEED in single units (use EACH, not pad, package, box, carton, etc.). Make a PHOTOCOPY for your records. Allow 3 weeks for processing and delivery. Complete this form and mail it to: ADMINISTRATIVE TRIBUNAL PO BOX 30763 LANSING MI 48909 You may also fax your order to: (517) 334-9505 REQUESTER INFORMATION: Requesting Business or Office Name Date of Request Attention of Approval Signature(s) (as needed) Phone Number ( ) Delivery Address (Number and Street) City State ZIP Code REQUESTED ITEMS: 1 COMMODITY NUMBER 4829 - 2 QUANTITY NEEDED EACH 3 4 FORM or ENVELOPE FORM or ENVELOPE TITLE IDENTIFICATION NUMBER (NOT Pad, Pkg, Box or Ctn.) 0092 DCH-0092 Request For An Administrative Hearing 0093 DCH-0093 Hearing Request Withdrawal 0367 DCH-0367 Hearing Summary 0368 DCH-0368 0646 DCH-0646 Administrative Tribunal – Business Reply Envelope Administrative Tribunal Requisition Forms (preprinted – not electronic fill-in enabled) AUTHORITY: COMPLETION: None Voluntary, but this information is required to obtain a supply of the above printed materials. For Office Use Only Administrative Services Approval Date Processed The Department of Community Health is an equal opportunity employer, services, and programs provider. DMB - Processed by 247 Directions for Completion, Use and Submission of Local Appeals Log The purpose of the Local Appeal Form is to initiate the local appeal process and to supply information needed to review with process a local appeal. Use the Local Appeal Log to document all ACTIONS and Local Appeal Requests for the month and relevant information as indicated below. If no local appeals were requested during the reporting month, please indicate on log. 1. Internally track documents related to all ACTIONS. 2. When a request (oral or written) is submitted, the appeals coordinator or staff person responsible will initiate the review process and document information on the Local Appeals Log. 3. Completion of the log should occur as the incident occurs and follow the standard or expedited process and standards timeline. 4. Forward Local Appeal Request to Agency per the Local Appeal policy & attachments upon request/as needed. 5. The form is divided into three parts. a. Beneficiary Information b. Local Appeal Request c. Local Appeal Disposition 6. The complete log must be sent to the Agency- Utilization Management Department, Attn: Appeals Coordination by the 10th day of the following month. 7. Fax log to (313) 833-3670 or email to dlasenby@co.wayne.mi.us along with the documents listed below. 8. Upon receipt of a Local Appeal Request Form, the service provider must send the Letter to acknowledge the request the Local Appeal Request. Follow the policy and timeline standards to review and decision of appeal. ** Note: The service provider will send the request for a local appeal and the following documents to the Agency's Attention UM/Appeals Coordinator@(313) 833-3670 upon request for consultation or additional review. 1. Individual Plan of Service 2. Notice of Action: Medicaid Fair Hearing and Local Appeals Rights form 3. Copy of Adequate or Advance Notice sent to beneficiary 4. Copy of completed Local Appeal Request Form 5. Local Appeal Acknowledgement Letter 6. Relevant Process Notes 7. Treatment Plan and Treatment Plan Review 8. Copy of Psychiatric Assessment Section 1Beneficiar y Informatio n Enter the following information as defined below: CMH Link # Enter the beneficiary's CMH Link Member ID# Date of IPOS Date of Individual Plan of Service centered Planning Meeting)- (Person- 248 Section 3 - Local Section 2 - Local Appeal Request Appeal Disposition Planned Start Date of Service Enter IPOS agreed upon start date Planned End Date of Service Enter IPOS agreed upon end date Commencement (Actual Start) Date Date the services or supports actually begin Level of Care / Covered Services Services receiving that are impacted by Action planned or taken MCPN (Key Below) Please enter the beneficiary's assigned Manager of Comprehensive Provider Network Proposed Date of Action Enter effective date for Action per Notice Action (Key Below) Enter actual date the action took place or is scheduled for implementation Date of Notice Enter date action was decided and notice prepared (including date provided to beneficiary (if done face to face) Adequate -1 Advance - 2 Indicate by # type of notice provided to beneficiary Date of Appeal Request Actual date the beneficiary /legal rep. requested the local appeal Oral - O Written - W Please indicate whether initial request was made orally or in writing Expedited - E Standard - S Indicate by # type of beneficiary Date of Acknowledgement Letter Enter date Acknowledgement letter mailed Continued = C Reinstated = R Not Applicable = NA Indicate status of Medicaid covered services that are affected by action. resolution requested by Date of Local Appeal Review Name of Reviewer with Credentials Resolution (See Key) Date of Disposition Notice (letter) Date of Disposition mailed Please email completed log by the 10th of month to dlasenby@co.wayne.mi.us 249 Local Appeal Log Service Provider: ___________________ Completed by: ________________________ CMH Member ID# 1 Month/Year: _____________________ 2 3 4 5 Date of IPOS Planned Start Date of Service Planned End Date of Service Commencement (Actual Start) Date Level of Care / Covered Services MCPN (Key Below) Proposed Date of Action Action (Key Below) Date of Notice Adequate -1 Advance - 2 Date of Appeal Request Oral - O Written - W Expedited - E Standard - S Date of Acknowledgement Letter Continued = C Reinstated = R Not Applicable = NA Date of Appeal Review Name of Reviewer w/h Credentials Resolution (See Key) Date of Disposition Notice (letter) & Form Date of Disposition mailed MCPN Key: CR= Carelink G= Gateway CN = Consumer Link CLS = Community Living Services S = Synergy Action Key: 1 = Denial of public mental health/substance abuse services for an applicant 2 = Reduction of services 3 = Denial of service to a current consumer (something currently not receiving) 4 = Suspension of services 5 =Termination of services Resolution Key: 1 = Agree with Action, decision remains 2= Disagree with Action, decision reversed Please email completed log by the 10th of each following month to dlasenby@co.wayne.mi.us 250 Local Appeal Monitoring Tool DETROIT-WAYNE COUNTY COMMUNITY MENTAL HEALTH AGENCY/MCPN & CA MONITORING TOOL FOR EQR STANDARD XIV LOCAL APPEALS (REVISED 12-07) ORGANIZATION: EVALUATION ELEMENTS 1. Appeals The Service Provider has internal appeals procedures that address: CFR 42.438.402, MDCH 6.4(B) Attachment P6.3.2.1 2. Local Appeals Process In handling appeals, the Service Provider meets the following requirements: CRITERIA DATE OF REVIEW: EXAMPLES of EVIDENCE SCORING The method for a beneficiary to obtain a hearing. 1.Copy of internal policies and procedures 2.Documents signed by beneficiaries as proof of IPOS – Notice of Action: Medicaid Fair Hearing & Local Appeal Rights Appeal Procedures: Met Substantially Met Partially Met Not Met Not Applicable Acknowledges receipt of each appeal, in writing, unless the beneficiary or provider requests expedited resolution. 1. Local Appeal Acknowledgement Form on beneficiaries’ charts with copy of this and Local Appeal Request Form sent to Agency as requests are made within 3 calendar days. 2. Documentation on Local Appeal Log submitted to Agency by 10th day of following month. Local Appeal ProcessAcknowledgment: Met Substantially Met Partially Met Not Met Not Applicable Ensures that oral inquiries seeking to appeal an action are treated as appeals in order to establish the earliest possible filing date. 1. Copy of Local Appeal Acknowledgement Form on beneficiaries’ charts with copy of this and Local Appeal Request Form sent to Agency as requests are made within 3 calendar days. 2. Documentation on Local Appeal Log submitted to Agency by 10th day of following month Oral Inquiries: Met Substantially Met Partially Met Not Met Not Applicable FINDINGS CFR 42. 438.406(a)(2), (c)(1), Attachment P6.3.2.1 CFR 42.38.406(b)(1) Attachment P6.3.2.1 251 EVALUATION ELEMENTS CFR 42.38.406(b)(1) Attachment P6.3.2.1 3. Expedited Process CFR 42.438.410(a) Attachment P6.3.2.1 4. Individuals Making Decisions—Not Previously Involved CFR 42.438.406(a)(3)(i) Attachment P6.3.2.1 5. Individuals Making Decisions—Clinical Expertise CFR 42.438.406(a)(3)(ii) CRITERIA EXAMPLES of EVIDENCE SCORING Maintains a log of all requests for appeals and reports data to the Service Provider quality assessment & performance improvement program. Documentation on Local Appeal Log submitted to Agency by 10th day of following month. Appeals Log: Met Substantially Met Partially Met Not Met Not Applicable The Service Provider has an expedited review process for appeals when the Service Provider determines (from a request from the beneficiary) or the provider indicates (in making the request on the beneficiary’s behalf or supporting the beneficiary’s request) that taking the time for a standard resolution could seriously jeopardize the beneficiary’s life or health or ability to attain, maintain, or regain maximum function. 1. Copy of internal policies and procedures 2. Copy of Local Appeal Request Form sent to Agency as requests are made within 1 calendar day. 3. Documentation on Local Appeal Log submitted to Agency by 10th day of following month Expedited Process: Met Substantially Met Partially Met Not Met Not Applicable The Service Provider ensures that individuals who make decisions on appeals are individuals who were not involved in any previous level of review or decisionmaking. 1. Copy of internal policies and procedures 2. Copy of Local Appeal Request Form sent to Agency as requests are made. Staff Reviews: Met Substantially Met Partially Met Not Met Not Applicable The Service Provider ensures that individuals who make decisions on appeals have the appropriate clinical expertise in treating the beneficiary’s condition or disease when deciding any of the following: An appeal of a denial that is based on lack of medical necessity Documentation in the beneficiary’s file – copy of Local Appeal Disposition Notice and form that demonstrates the staff that reviewed and processed the Local Appeal request is a credentialed clinician. Clinical Expertise: Met Substantially Met Partially Met Not Met Not Applicable FINDINGS 252 EVALUATION ELEMENTS EXAMPLES of EVIDENCE CRITERIA Attachment P6.3.2.1 An appeal that clinical issues 6. Right to Examine Records The appeals process provides the beneficiary and his or her representative the opportunity, before and during the appeals process, to examine the beneficiary’s case file, including medical records and any other documents and records considered during the appeals process. The Service Provider provides written notice of the results of a standard resolution as expeditiously as the beneficiary’s health condition requires, but no later than 45 calendar days from the day the Service Provider received the request for a standard appeal and no later than three working days after the service provider received a request for an expedited resolution of the appeal. The notice of disposition includes an explanation of the results of the resolution and the date it was completed. CFR 42.38.406(b)(3)(ii) 7. Notice of Disposition CFR 42.438.408(b) Attachment P6.3.2.1 8. Notice of Disposition CFR 42. 438.408(e) Attachment P6.3.2.1 9. Appeals Not Resolved in Favor of Beneficiary SCORING FINDINGS 1. Copy of internal policies and procedures 2. Documentation that opportunity was presented and if beneficiary chooses to review, documentation of date, time and information reviewed. Examine Records: Met Substantially Met Partially Met Not Met Not Applicable . Documentation on the beneficiary’s file – copy of Local Appeal Disposition Notice and form that demonstrates the staff that reviewed and processed the appeals completed within time standards. Standard Disposition: Met Substantially Met Partially Met Not Met Not Applicable Documentation on the beneficiary’s file – copy of Local Appeal Disposition Notice and form that demonstrates that the staff that reviewed and process the appeals completed within time standards Documentation on the beneficiary’s file – copy of Local Appeal Disposition Notice that demonstrates the staff that reviewed and processed the appeals the notice includes instructions and forms with postage paid envelope for the Hearing Expedited Disposition: Met Substantially Met Partially Met Not Met Not Applicable involves When the appeal is not resolved wholly in favor of the beneficiary, the notice of disposition includes: * The right to request a Medicaid Fair Hearing. * How to request a Medicaid Fair Hearing. * The right to request to receive benefits while the State fair hearing is Appeal Resolution: Met Substantially Met Partially Met Not Met Not Applicable 253 EVALUATION ELEMENTS CFR 42.438.408(e)(2) Attachment P6.3.2.1 10. Denial of a Request for Expedited Resolution of an Appeal CRITERIA EXAMPLES of EVIDENCE pending, if requested within 12 days of the Service Provider mailing the notice of disposition, and how to make the request. The fact that the beneficiary may be held liable for the cost of those benefits if the hearing decision upholds the Service Provider action Request Form. If a request for expedited resolution of an appeal is denied, the Service Provider: Transfers the appeal to the time frame for standard resolution (i.e., no longer than 45 days from the date the SERVICE PROVIDER received the appeal). Makes reasonable efforts to give the beneficiary prompt oral notice of the denial. Gives the beneficiary follow-up written notice within two calendar days. 1. Documentation on the beneficiary’s file – copy of Local Appeal Disposition Notice and form that demonstrates that the staff that reviewed and process the appeals completed within time standards 2. Copy of Local Appeal Request Form sent to Agency as requests are made with detail of timeline compliance with submission, processing with the appropriate disposition notices. SCORING FINDINGS Denial of Expedited Resolution: Met Substantially Met Partially Met Not Met Not Applicable CFR 42.438.410(c) Attachment P6.3.2.1 254 (INSERT SERVICE PROVIDER LETTERHEAD) <Service Provider> <address> <phone> <fax>. LOCAL APPEAL ACKNOWLEDGEMENT Date Name Address City, State, Zip RE: Name: CMH Link ID#: Dear ____________: We received your Local Appeal request on <insert date>. It may take up to 45 calendar days for a resolution. Once a decision has been made, you will receive a letter and the resolution in the mail. If you have any questions, please do not hesitate to contact <Individual Responsible for Local Appeals> at <phone>. Sincerely, <Name of Responsible Party> <Title> 255 (INSERT SERVICE PROVIDER LETTERHEAD) <Service Provider> <address> <phone> <fax>. LOCAL APPEAL NOTICE OF DISPOSITION Date Name Address City, State, Zip RE: Name: CMH Link ID#: Dear ____________: Enclosed is the resolution of the local appeal that was filed on your behalf. If you do not agree with this action, you may also request a Michigan Department of Community Health fair hearing within 90 calendar days of the date of the Action Notice. Hearing requests must be made in writing and signed by you or an authorized person. To request a fair hearing, complete the “Request for Hearing” form, and mail to: ADMINISTRATIVE TRIBUNAL MICHIGAN DEPARTMENT OF COMMUNITY HEALTH P.O. BOX 30763 LANSING, MI 48909-7695 You have a right to an expedited hearing if waiting for the standard time for a hearing would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited hearing, you must call, toll-free, 877-833-0870. Sincerely, <Name of Responsible Party> <Title> Enclosures: Hearing Request Form & postage paid envelope 256 LOCAL APPEAL DISPOSITION FORM Consumer Name Telephone# Date of Birth: Address (No. & Street, Apt#, etc.) Date Appeal Requested Date Resolution City of State ZIP Code What Service Provider took the action or made the decision leading to the Local Appeal Request: Local Appeal Request Standard Request Expedited Request EXPLAIN/DESCRIBE THE APPEAL ISSUE (You may attach additional pages if necessary): ADDITIONAL INFORMATION/FINDINGS: RESOLVED: YES NO Date_______________ RESOLUTION: ______________________________________________ Signature of Person completing form ______________________ Date 257 DETROIT-WAYNE COUNTY COMMUNITY MENTAL HEALTH AGENCY REPORT OF CRITICAL EVENT / SENTINEL EVENT FORM Initial Update Sentinel Events must be reported by telephone to the Agency's (D-WCCMHA) Office of Quality Management within (1) business day – (313) 833-4198 This form must be typed, completed and submitted to the Agency's (D-WCCMHA) Office of Quality Management within two (2) business days of notifying D-WCCMHA,– Fax # (313) 967-7706 1. Date of Report: ___________________________________________________ 2. Name of Service Provider: __________________________________________ 3. Staff: ___________________________________________________________ 4. Name of Individual Receiving Services: ________________________________ 5. DOB: ___________________________________________________________ 6. SS# ____________________________________________________________ 7. MH-WIN #:_______________________________________________________ 8. Setting: Assertive Community Treatment Program (ACT) Children’s Waiver (SED or DD) Habilitation Supports Waiver (HSW) Michigan Prison Release Initiative (MPRI) Own Home / Community Living Supports Other (i.e., emergent service) ______________________________________ Substance Abuse Residential Treatment Program Supports Coordination Targeted Case Management Wraparound Program Homebased Program Discharged from State Hospital within last 12 months Discharged from State Facility within last 12 months Specialized Residential and/or Child Caring Institution Name of AFC or CCI __________________________________________ MDHS License # _____________________________________________ 9. Type of Critical Event and/or Sentinel Event Injuries that require: Emergency medical treatment in an ER, medi-center, urgent care clinic/center 258 Admission to hospital as a result of an incident resulting from abuse, neglect Accident or loss of limb or function Medication error Physical management (include type of intervention and length of time) Arrest Conviction Medication Error (wrong medication, wrong dosage, double dosage, or missed dosage resulting in risk of harm or adverse reaction(s) or the risk thereof or emergency medical treatment or hospitalization Physical Illness requiring admission(s) to a hospital(s) (do not include planned surgeries, whether inpatient or outpatient OR admissions directly related to the natural course of the person’s chronic illness or underlying condition) Medication error Injury Physical illness Challenging Behavior not already addressed in the IPOS (include property damage >$100; attempts at self-inflicted harm or harm to others; or unauthorized leave(s) of absence) Behavior plan Suicide attempt Harm to others Physical management Police intervention No Yes – If yes, attach a copy No Yes – If yes, attach a copy of case record information No Yes – If yes, what type of intervention was used No Yes – If yes, what type of intervention was used and length of time No Yes Death (not a direct result of the natural outcome to a chronic condition or old age) 10. Death Log # __________ Non-suicide death Suspected suicide No Yes – If yes, attach a copy of case record information Detail Summary of Review: 259 11. Detail Summary of Findings/Decision: 12. Detail Summary of Action(s) Taken: 13. Detail Summary of Follow-up: Signature: _______________________________________________________ Date: ___________________________________________________________ Phone # _________________________________________________________ Fax # ___________________________________________________________ E-mail _________________________________________________________ 260 SAMPLE FORM: PSYCHOTROPIC MEDICATIONS CONSENT FORM Medication Date Started 6/1/98 A. Paxil B. Lithium 12/22/98 C. Prozac 10/22/99 Date Discontinued 12/22/00 D. E. (This section should contain the general narrative regarding informed consent; i.e., have had opportunity to address questions to the physician, aware of risk vs. benefits can withdraw consent at any time, etc.) I HAVE BEEN PROVIDED WITH A WRITTEN SUMMARY OF THE MOST COMMON ADVERSE EFFECTS THAT HAVE BEEN ASSOCIATED WITH THE DRUG(S) NAMED ABOVE. Parent/Guardian Signature Date Witness Signature Date 261 Provider Data Worksheet The MCPN will complete this form with all data fields completed 5 business days before the start date of the contract. All added subcontractors must have signed contracts and, as of April 1, 2003, must have executed HIPAA and State of Michigan privacy agreements as needed. The Agency will review and check contracts periodically with the MCPN as part of the Agency’s due diligent responsibilities. Date Submitted: Provider Network Manager (MCPN): MCPN Subcontractor Name: Subcontractor Federal Tax ID (38-#######): Subcontractor Medicaid ID Subcontractor National Provider Identifier Subcontractor contact name: Subcontractor contact phone: Subcontractor Physical Locations: Site Address 1 Address 2 City ST Zip Code Main Phone 1 2 3 4 5 6 Subcontractor Location 1 Purchased Services: Site 1 1 1 1 1 1 Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other 262 Subcontractor Location 2 Purchased Services: Site Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual 2 2 2 2 2 2 □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other Subcontractor Location 3 Purchased Services: Site Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual 3 3 3 3 3 3 □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other Subcontractor Location 4 Purchased Services: Site 4 4 4 4 4 4 Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other 263 Subcontractor Location 5 Purchased Services: Sit e 5 Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual 5 5 5 5 5 □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other Subcontractor Location 6 Purchased Services: Sit e 6 Service Description Procedure Code(s) Reimbursement Method □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual □ Sub Cap contractual 6 6 6 6 6 □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other □ per diem □ other (Please use an additional form if the subcontractor has more than 6 locations) If the contractual arrangement is for residential services, list the maximum number of beds committed to the MCPN in the contract. Subcontractor Purchased Service Capacity: Site Number of Beds Location State License Number Contracted 1 2 3 4 5 6 264 Below is used for Agency only Date Received: Date Entered into CMH-Link: Subcontractor CMH-Link Identifier: Entered by: 265 Customer Services Forms 266 MCPN New Enrollee Welcome Letter January 26, 2007 Welcome New Member: Thank you for choosing _____________________________________as your Manager of Comprehensive Provider Network (MCPN). We are happy to offer you service and supports through our network of doctors, therapists, home providers, staffing agencies, and employment providers. During your orientation you will be provided information that describes the array of service available through our provider network. You will also receive information regarding the following: Advance Directives Emergency After-Hour Services (including 911 access) Recipients Rights Grievances and Appeals Person Centered Planning Your Enrollee Rights Kevin’s Law Out of Network Services New Intended Beneficiary Orientation Video Please feel free to contact a Customer Service Representative if you have any questions our toll free number is_____________. Members with hearing impairments can contact our teletypewriter (TTY) at (866)___________. Once again, thank you for choosing ________________. We look forward to serving your needs. Sincerely, 267 Intended Beneficiary Feedback Form (optional) What: Intended Beneficiary Orientation to Services Where: ______________________________________ Service Provider Name: ________________________ How was your Orientation? 1. The orientation helped you to understand what Services are available to you and how you can access them? ___Yes ___No Comments: ___________________________________________________________________________ 2. The orientation informed you about your enrollee rights? ___Yes ___No Comments: ___________________________________________________________________________ 3. Were you informed of your right that updated informational materials upon and additional information will be provided on an annual basis? __Yes enrollment __No Comments: __________________________________________________________________________ 4. Were you told how to obtain after-hour emergency services and that prior not required? __Yes authorization is __No Comments: ________________________________________________________________________ ********* Date of Orientation: _______________________________ Thank you for completing this evaluation. This will help us in providing you with better service. Your information will remain confidential. (Provider Instructions: Please have Consumer complete. Fill in your MCPN Name and return to your Customer Service Representative for submission at your MCPN.) 268 D-WCCMHA Intended Beneficiary Orientation Receipt Form Case Record File Copy I hereby acknowledge that I was presented with an Orientation Packet and provided information on the benefits, services and how to access these services. I was also provided the opportunity to ask questions and was also given the phone number to call should I have any additional questions at a later time. I Received the Following Information (Please check all that apply) _ DWCCMHA Consumer Handbook _ Grievances and Appeals Pamphlet _ Recipient Rights Handbook _ Welcome Letter from MCPN _ DWCCMHA Customer Service Brochures _ Service Provider Informational Materials _ List of Non-English Language Providers _ List of Providers Not Accepting New Members _ Kevin’s Law _Presentation of New Intended Beneficiary Orientation Video Name Printed: ______________________ Signature:__________________________ Date:_______________________________ Orientation Facilitator:__________________ 269 D-WCCMHA Intended Beneficiary Orientation Customer Service Monthly Report MCPN NAME: ____________________ REPORTED MONTH: _______________ Orientation: Provider Site: Name Monthly Report Year to Date Report Comments Evaluation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Prepared By: 270 Results for Standard VI: Customer Service DWCCMHA Customer Service MCPN Monthly Activity Performance Tracking Report Month/Year: ___________________ Submitted By: ___________________ Agency to Complete MCPN Name:________________________________ Current Enrollment: ______________ Activity Jan. Feb Mar April . May June July Aug. Sept. Oct . Nov. Dec. YTD 1 Customer Service Calls Resolved within 24 hrs. 2 Customer Service WalkIns 3 New Enrollee Orientations **New Enrollee Evals. Submitted 4 Grievances Processed Grievance Pending Griev. Resol. Post 60 days 5 New C.S. Staff Orientations *(Staff Trainings) # of Attendees Reviewed by Agency Customer Service Staff: ___________________ Attachments:*1. Listing of C.S. Trainings w/dates and Locations **2. New Enrollee Orientation Evaluation Form Date: ____________________ 271 SAMPLE - CUSTOMER SERVICES MONITORING TOOL Customer Service Assessment Fiscal Year 11/12 On each form, please include the Date: MCPN: Contract: Reviewer: 272 Elements Criteria Standard VI: Customer Service 1. Identifiable Function DWCCMHA Customer Service Policy Standard V, J, and M Intended Beneficiary Policy Standard V Grievance and Appeals Policy Standard V Customer Service is an identifiable function that operates to enhance the relationship between individual and the MCPN and includes: Customer Service Policy A designated Customer Service unit with at a minimum of a one full time equivalent. If functions are delegated there shall be additional FTE (or fraction thereof) appropriate to meet the need of the people in the service area PIHP Contract 6.3.1 2. Access DWCCMHA Customer Service Policy Standard V C MDCH PIHP AFP 6.3 3. Informed Staff DWCCMHA Customer Service Policy Standard V M 4. Feedback from Orienting new individuals to the services and benefits available, including how to access them; Helping individuals with problems and questions regarding benefits; Handling individuals complaints and grievances in an effective and efficient manner; and Tracking and reporting patterns of problem areas for organization. Customer Service facilitates phone access by the community and service recipients throughout normal business hours. (Note: Voice mail and answering machines are not considered phone access.) Customer Service staff has up-to-date knowledge regarding benefits, the provider network, applicant and network policies / procedures regarding access, service authorization, and grievance / appeal procedures and are skilled in customer relations. There is a documented process Evidence Comments Scoring MCPN Customer Services Policy Recipient handbooks Policies / procedures /protocols for: Orienting new individuals / responding to questions about the services and benefits available to them Handling complaints and grievances Logs / documentation of response to the above Reports of trends, patterns of problem area Organization Chart Met Partially Met Not Met N/A Informational materials identifying hours of operation of customer service Customer Service phone number Met Partially Met Not Met N/A Documentation of training materials for Customer Service staff Sign in Sheets Interviews of Customer Service Staff Met Partially Met Not Met N/A Policies Met Partially Met and 273 Stakeholders MDCH PIHP AFP 6.3 5. Standards DWCCMHA Customer Service Policy VI Performance Measurements B whereby service or process improvement suggestions from individuals are routed in a timely manner to the appropriate part of the MCPN. Customer Service performance standards of effectiveness and efficiency are documented and periodic reports of performance are monitored. procedures / protocols for handling suggestions from individuals Not Met N/A MCPN documented Customer Service performance standards MCPN monitoring performance results Met Partially Met Not Met N/A: MDCH PIHP AFP 6.3 Elements Criteria Standard VI: Customer Service 6. Cultural Sensitivity and Reasonable Accommodations DWCCMHA LEP Accommodations for Individuals with Visual, Mobility, Hearing Impairments Policies MDCH PIHP AFP 6.3 7. Relationship to Grievances and Appeals DWCCMHA Customer Service Policy Grievance and Appeals Policy Evidence Customer Service is managed in a way that addresses the need for Cultural Sensitivity and Reasonable Accommodations for Consumers with physical disabilities, hearing and / or vision impairment, Limited-English Proficiency, and alternative communication. The relationship of Customer Service to required grievance and appeals and recipient rights processes is clearly defined organizationally and managerially in a way that ensures effective coordination of the functions, and avoids conflict of interest or purposes within these functions Comments Scoring Customer Service Accommodation policies and procedure Cultural Competency plan Met Partially Met Not Met N/A Customer Services policies and procedures Functional Organizational Chart Recipient Rights Policies Met Partially Met Not Met N/A PIHP Contract 6.3.2 274 8. Delegation (as Applicable) 42CFR, 438.230(b)(2)(i) PIHP Contract 5.0, Observance of Federal, State, and Local Laws, and 6.42 Subcontracting Requirements, Customer Service Policy Standard VI Performance Measurements 438.230(b)(4) The MCPN oversees and is accountable for any Customer Service functions it delegates to any subcontractor. Before any Customer Service delegation, the MCPN evaluates the subcontractor’s ability to perform the delegated activity There is a written agreement that specifies the activities and report Customer Service responsibilities designated to the subcontractor. There is a written agreement that provides for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate. The MCPN monitors the subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by the DWCCMHA. The MCPN monitors the subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by the DWCCMHA. If the MCPN identifies deficiencies or areas for improvement, the MCPN and the subcontractor take corrective action. List of delegated Customer Service functions by subcontractor Evidence of evaluations performed prior to entering into contracts Written Customer Service agreement with the- subcontractor Evidence of on-going or periodic monitoring Evidence of formal reviews per timeline established by the DWCCMHA Evidence / examples of identifying deficiencies and corrective action taken Met Partially Met Not Met N/A 275 Page intentionally left blank 276
