Region 1 South
Crisis Care System
Concurrent Review
Region 1 South
Crisis Care System
Presenters: Lee Ann Reinert, LCSW
Clinical Policy Specialist, DHS/DMH
Patricia Palmer, LCSW, CADC
Clinical Director, Collaborative
Author: Patricia E. Hill, CSS
Summary: This document will review the procedures regarding
concurrent review for inpatient care in a CHIPS hospital
Continued Stay Request
 If the Consumer is still hospitalized when the Initial
Authorization timeframe is up, they will need a concurrent
review for continued stay
 24 hours before the expiration date (or on the preceding
Friday if a weekend), the attending physician and/or designee
will contact the Collaborative at (866)359-7953 and select
option “#4” to request an authorization for continued stay
 Concurrent authorizations must be done during regular business
hours (Monday – Friday, 8 am – 5 pm)
Continued Stay Request
 The Collaborative will review the clinical information to verify
that the Consumer meets the Medical Needs Criteria (MNC)
for Continued Stay
 Medical Needs Criteria includes both Severity of Illness and
Intensity of Services criteria
Medical Needs Criteria
 Severity of Illness Criteria
 Individual requires continuous skilled psychiatric observation,
planned psycho-therapeutic services, and/or psychotropic drug
management
 Individual exhibits an inability to care for self due to an
interaction of mental and their physical disorders creating
incapacitating symptoms or behaviors
 Individual poses significant suicide risk
 Individual has a history of assaultive or self-mutilating behavior
or reported evidence of being a danger to self or others
 Individual exhibits homicidal behavior accompanied by a
psychiatric disorder
 Individual exhibits impaired reality testing accompanied by
disordered behavior
Medical Needs Criteria
 Intensity of Services Criteria
 Complex treatment is necessary due to co-existing conditions
requiring concurrent treatment
 There is a need for a controlled environment in order to protect
self and others
 Specialized treatment modalities are only available in the
hospital due to need for special environment, equipment or
ancillary services
 There is a high potential for readmission within 30 days; medical
record MUST reflect efforts taken to address these issues
Continued Stay Request
 Areas addressed during the review call include
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Who has evaluated them and the results of all evaluations
Current mental status including risk to self or others
Current impairments
Are they on meds; if so, what
Has family treatment occurred and when
What is their baseline functioning
What is the treatment plan
What is the discharge/transition plan and estimated length of
stay
 Diagnoses on all 5 axes
Continued Stay Request
 After reviewing the clinical information presented, the
Collaborative will verify that the Consumer does or does not
meet the Medical Needs Criteria (MNC) for Continued Stay
 Once the Consumer has been approved, the Collaborative will
issue a Concurrent Review Authorization
 If longer term services are indicated, the hospital should
make arrangements for a more appropriate care setting (i.e.
state hospital, nursing home, etc.)
Decisions
 A PA Review is conducted if there is a difference of opinion
concerning a request for extended length of stay for the
consumer
 If the PA Review agrees, services will be authorized
 If the PA Review does not agree with the extension, a
Second Level Reconsideration Review will be conducted
with another VO MD
 If the PA Second Level Reconsideration Review agrees,
services will be authorized
 If the Second Level Reconsideration Review remains
unresolved then DMH will make the final determination
www.illinoismentalhealthcollaborative.com
(888) 359-7953