Medical Necessity for Child Case Managers

Amy L. Simonds, MS, MA, LCPC6/09

Objectives

• Participants will define medical necessity.

• Participants will complete required documentation relative to medical necessity requirements.

• Participants will defend medical necessity criteria in their continued stay requests.

Federal standards of medical necessity

• “any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level” (Federal Register, Section 1905(a)(13) of the Act and 42 CFR 440.130(d)).

Maine’s medical necessity

1.provided in an appropriate setting;2.recognized as standard medical care, based on national standards for best

practices and safe, effective, quality care;3.required for the diagnosis, prevention and/or treatment of illness, disability,

infirmity or impairment and which are necessary to improve, restore or maintain health and well-being;

4. MaineCare covered service (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter II, Section 94 of this Manual);

5.performed by enrolled providers within their scope of licensure and/or certification; and

6.provided within the regulations of this Manual

Adams & Grieder:

• “Simply stated, the documentation of medical necessity is the clear demonstration that there is a clinical need and that services provided are an appropriate response.”

Treatment Planning for Person-Centered Care, Neal Adams, Diane M. Grieder, ElSevier Academic Press, 2005.

What do you do (at work)?

• Use the next 2 minutes to brainstorm a list of tasks you do at work most days.

What does Maine Care reimburse for?• On your list star all of the activities Maine

Care reimburses for.

The Maine Care regulations:

• Assessment• Individual plan (ISP)• Coordination/advocacy• Monitoring • Evaluation

Assessment

• “The case manager will coordinate a comprehensive assessment of the child or adolescent in consultation with team members (professionals, providers, family or guardians, and the child or adolescent) as necessary. The appropriate professionals, acting within the scope of their licenses, will complete the clinical components of the comprehensive assessment.” (Maine Care Regulations, section 13.12, p. 42)

Medical necessity starts with the referral and the assessment• The case manager should read the

assessment to determine:– Eligibility criteria are met– Treatment recommendations for case

management are noted in the summary• Case management to do what?

Decision tree• Eligibility criteria are met?

– Yes. Proceed.– No. Do an addendum if the client meets eligibility,

but it’s not documented in the summary (ex., child case management must be explicitly stated in the summary).

• Case management role/tasks are defined in the summary?– Yes. Proceed.– No. Do an addendum to indicate the needs and

indicate the role of case management in the summary section

Assessment review

• Does this client qualify for child case management?

• Do you have enough information to base some ISP goals off of?

Individual Plan (ISP)

• “The case manager will coordinate development of an individualized plan of care, based on the comprehensive assessment. The Individual Support Plan (ISP) is a holistic plan involving all service providers and agencies. It encompasses the respective plans developed by each involved agency…” (Maine Care Regulations, Section 13.12, p. 43)

The ISP is a service contract

• Who are you contracting with?– Parents– Other providers– Children– Maine Care

• What are you contracting for?– Covered services

Covered services

• Assessment• Individual plan (ISP)• Coordination/advocacy• Monitoring• Evaluation

Limitations

• You only get paid for the covered services listed on the ISP and referred to in the assessment!

Review ISP and assessment

• Are the tasks listed on the ISP reimbursable through Maine Care?

• Why or why not?

Progress notes

• Must relate to the ISP and indicate what the case manager actively did during the time they billed.

• If a consultation call was made:– How long?– To whom?– For what?– Outcome?

Home visit:

• When was it?• Who was there?• What was the purpose?

– “Scheduled visit” isn’t enough. “Scheduled visit for review of client’s progress” is.

• What was the outcome?– Is the client improving? Decompensating? No

change? – Is there a change to the service plan?

Coordination/Advocacy• “The case manager will provide coordination

and advocacy services, the purpose of which is to ensure that the child or adolescent has access to and utilizes the services and resources identified in the ISP. Specifically, the case manager will coordinate the multiple providers of services identified in the ISP, will ensure appropriateness of services, and will advocate on behalf of the child or adolescent and his or her parent or guardian.” (Maine Care Regulations, Section 13.12, p. 43 - 44)

Monitoring

• “The case manager will provide monitoring services to ensure full implementation of the ISP. Monitoring will assess the child or adolescent’s progress toward meeting objectives outlined in the Individual Support Plan and will be accomplished by an ongoing in-person contact with the member and his or her parent or guardian.” (Maine Care Regulations, Section 13.12, p. 44)

Evaluation• “The case manager will provide evaluation services

quarterly to determine whether the Individual Support Plan is appropriate and effective. If necessary, as part of the evaluation, the case manager will convene the Child and Family Team, other providers, and family members for consultation. Following the evaluation, the case manager will continue the plan as written, modify the plan, revise the goals, or terminate services, based on the results of the evaluation process.” (Maine Care Regulations, Section 13.12, p.44)

Non-covered services

• “Habilitation services, which are health and social services that encompass training in intellectual, sensory, motor, and affective social development.” (Maine

Care Regulations, Section 13, p. 88)

• Transportation• Counseling and therapy• Services provided while the child is in the

hospital or other inpatient setting• Direct services reimbursable under other

sections of Maine Care • Services provided by parents or other relatives

of a minor