dmc-ods implementation requirements...dmc-ods implementation requirements march 2019 presented by...
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DMC-ODS IMPLEMENTATION REQUIREMENTS
MARCH 2019PRESENTED BY – KAKOLI BANERJEE, PH.D
Agenda
Update on 2018-19 Inter-governmental Agreement (IGA) (also the contract with DHCS), also STC (standard terms & conditions)
SCC SUTS Contract with DHCS
By signing the contract -Inter-governmental Agreement (IGA) in 2017, SUTS became a PIHP (a Pre-paid Inpatient Health plan)-a Managed Care Plan (MCP)
(SUTS MCP is one of two MCPs operated by the SCC BHSD)
SUTS is contractually obligated to comply with IGA terms & implement all the components contained in the contract
When SUTS contracts out services, all service providers are also required to comply with IGA terms & conditions
The Inter-governmental agreement -IGA
The IGA is composed of two main sections; a general section and a county-specific section
The general section covers provisions that apply to all waiver opt-in counties: IGA requirements also align with 42 CFR Part 438 provisions
(Final Rule), which regulate the operation of public managed care plans
This presentation covers changes/updates in the general section of the IGA
Required IGA provisions –(applicable to all opt-in counties) fall into 3 categories
Clinical services, medical necessity,
Access, Coordination of care
Quality management & performance measurement
Business operations (42 CFR 438)
includes claims & reimbursement
Mandatory ASAM Levels of Care- No change
MANDATORY Withdrawal management (at least one
level) Outpatient services (ASAM Level 1.0) Intensive Outpatient Services (ASAM
Level 2.1) Residential treatment (at least 1 level) Opioid (Narcotic) Treatment Programs Recovery services Case Management Perinatal Residential Tx Svcs Physician consultation
OPTIONAL Partial Hospitalization Residential levels 3.3 & 3.5
REFERRALS TO: Medically Monitored Intensive Inpatient
Services (ASAM 3.7) Medically Managed Intensive Inpatient
Services (ASAM 4.0)
Covered services & service requirements:Changes/clarifications
Covered services & service requirements:Changes/clarifications
The Contractor shall accept, and reimburse, a claim from any subcontracted OTP/NTP provider (Referring OTP/NTP) that pays another OTP/NTP for providing courtesy dosing (Dosing OTP/NTP) to a beneficiary.
The Contractor shall use the reimbursement rate established in the OTP/NTP provider’s subcontract.
Covered services & service requirements:Changes/clarifications
Covered services & service requirements:Changes/clarifications
Service requirements-Access:Changes/clarifications
Service requirements-Access:Changes/clarifications
Service requirements-Access:Changes/clarifications
Service requirements-Medical necessity:Changes/clarifications-Reminder
All beneficiaries shall meet the following medical necessity criteria: a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders
(DSM) Fifth Edition for Substance-Related and Addictive Disorders with the exception of Tobacco-Related Disorders and Non-Substance- Related Disorders or be assessed to be at risk for developing substance use disorder (for youth)
the ASAM Criteria definition of medical necessity for services based on the ASAM Criteria
Service requirements-Medical necessity:Changes/clarifications
New language spells out the deadline for review The Medical Director or LPHA shall review each beneficiary’s personal, medical, and
substance use history if completed by a counselor within 30 calendar days of each beneficiary's admission to treatment date.
The Medical Director or LPHA shall document separately from the treatment plan the basis for the diagnosis in the beneficiary's record within 30 calendar days of each beneficiary's admission to treatment date.
Service requirements-Diagnosis:Changes/clarifications
Medical Director or LPHA shall: evaluate each beneficiary’s assessment and intake information if
completed by a counselor through a face-to-face review or telehealth with the counselor
to establish a beneficiary meets the medical necessity criteria. diagnosis shall be a narrative summary based on DSM-5 criteria,
demonstrating the Medical Director or LPHA evaluated each beneficiary’s assessment and intake information, including their personal, medical, and substance use history.
shall type or legibly print their name, and sign and date the diagnosis narrative documentation. The signature shall be adjacent to the typed or legibly printed name.
Service requirements-Physician signature on physical examination results:
Changes/clarifications
Physician signature requirements for the review of physical examination results are spelled out:
The physician shall type of legibly print their name, sign and date documentation to support they have reviewed the physical examination results.
The signature shall be adjacent to the typed or legibly printed name.
Service requirements-Clinical documentation:Changes/clarifications
Specific language from Title 22 was added to the following (section PP – 13 thru 18):
Treatment plan
Sign in sheet
Progress notes
Continuing services
Discharge
Reimbursement for documentation(see attachment)
QM/QI : Grievance & appealChanges/clarifications
Interval for responding to a grievance is spelled out:
MCP process for handling beneficiary grievances and appeals of adverse benefit determinations-
Acknowledge grievance and appeal within 5 calendar days of receipt
No other change in the grievance & appeal process
Business operations: Alignment with Parity ActChanges/clarifications
Parity in Mental Health and Substance Use Disorder Benefits
General Parity Requirement MCP shall not impose Quantitative Treatment Limitations, or Non-
Quantitative Treatment Limitations on (inpatient, outpatient, emergency care, or prescription drugs) other limitations permitted and outlined in this Agreement.
Quantitative Limitations-cumulative financial requirement for substance use disorder services not applied to medical services
Non-Quantitative Limitations-
Non-quantitative limitations defined
Non-Quantitative Treatment Limitation (NQTL)” means a limit on the scope or duration of benefits that is not expressed numerically.
Non-quantitative treatment limitations cover reasons medical reasons, prescription drugs, charges, needing proof to authorize higher cost services, failure to complete a course of treatment.
(Definitions of both will be posted on the website).
Business operations:Changes/clarifications
Two additions:
Number for reporting Medi-Cal fraud
Suspected Medi-Cal fraud, waste, or abuse must be reported to:
DHCS Medi-Cal Fraud 800-822-6222 or [email protected]
MCP Record retention policy
MCP must require providers to ‘to keep and maintain records for each service rendered, to whom it was rendered, and the date of service, pursuant to WIC 14124.1 and 42 CFR 438.3(h) and 438.3(u)’.
Business operations:Changes/clarifications
Network adequacy requirements for MCP spelled out & MCP is expected to:
Provide supporting documentation to demonstrate network adequacy for timeliness and access standards
Show that the locations, number and mix of services in the network sufficient to meet needs of beneficiaries
Network adequacy must be demonstrated annually in a DHCS approved format
Failure to comply with documentation requests will incur monetary penalties for the MCP
Comments & Questions
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