Section
3.14 Securing Services and Prior Authorization
3.14.1
Introduction
3.14.2 References
3.14.3 Scope
3.14.4 Objectives
3.14.5 Did you know?
3.14.6 Definitions
3.14.7 Procedures
3.14.7-A: Securing services that do not require
prior authorization
3.14.7-B: Accessing services that require prior
authorization
3.14.7-C. Prior authorization procedures
for behavioral health providers contracted by a RBHA
3.14.7-D. Prior authorization procedures
for behavioral health providers contracted by a Tribal RBHA
3.14.7-E. Prior authorizing medications
3.14.7-F. Coverage and payment of emergency
behavioral health services
3.14.1
Introduction
It is important that persons receiving behavioral health services
have timely access to the most appropriate services. It is also
important that limited behavioral health resources are allocated
in the most efficient and effective ways possible. Prior authorization
processes are typically used to promote appropriate utilization
of behavioral health services while effectively managing associated
costs. Except during an emergency situation, ADHS/DBHS requires
prior authorization before accessing inpatient services in a licensed
(OBHL) Level I facility (a psychiatric acute hospital, a residential
treatment center for persons under the age of 21 or a sub-acute
facility). In addition, a Regional Behavioral Health Authority (RBHA)
may require prior authorization of covered behavioral health services
other than inpatient services with the prior written approval of
ADHS/DBHS.
Behavioral health
services can be accessed for a person by one of two ways:
Securing
Most Behavioral Health Services:
Most behavioral health services do not require prior authorization.
Based upon the recommendations and decisions of the clinical team
(i.e., Child and Family Team or Adult Clinical Team), any and all
covered services that address the needs of the person and family
will be secured. During the treatment planning process, the clinical
team may use established tools to guide clinical practice and to
help determine the types of services and supports that will result
in positive outcomes for the person. Clinical teams should make
decisions based on a person’s identified needs and should
not use these tools as criteria to deny or limit services.
Securing
Services that Need Prior Authorization:
Prior authorization is required for certain covered behavioral health
services. Behavioral health services requiring prior authorization
include:
- Non-emergency
admissions to an OBHL Level I facility;
- Continued
stay in an OBHL Level I facility;
- Admission
to and continued stay in an OBHL Level II behavioral health residential
facility (Tribal RBHAs); and
- Admission
to and continued stay in an OBHL Level III behavioral health residential
facility (Tribal RBHAs).
When it is determined
that a person is in need of a behavioral health service requiring
prior authorization, a behavioral health professional applies the
designated authorization and continued stay criteria to approve
the provision of the covered service. A decision to deny a prior
authorization request must be made by the RBHA Medical Director
or physician designee, or for TRBHAs, by the ADHS/DBHS Medical Director
or physician designee.
This section
is intended to:
- Present the
distinctions between prior authorization of select behavioral
health services and securing of all other behavioral health services;
- Describe
federal requirements associated with authorization and denial
of inpatient services;
- Identify
the covered behavioral health services that must be prior authorized;
and
- Identify
how to access a covered behavioral health service that does not
require prior authorization.
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3.14.2
References
The following citations can serve as additional resources for this
content area:
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3.14.3
Scope
To whom does this apply?
All persons
that receive behavioral health services.
3.14.4
Objectives
To ensure that behavioral health services are secured or prior authorized:
- Consistent
with the Arizona Principles for persons receiving services through
the public behavioral health system; and
- According
to federal, state and T/RBHA requirements; and
- In a manner
that allows timely access to care based on the person’s
clinical needs.
3.14.5
Did you know?
- It is important
for a behavioral health professional to document enough information
in the comprehensive clinical record to validate that the prior
authorization request meets all elements of the authorization
criteria.
- The RBHA
may require prior authorization of behavioral health services
other than inpatient services only with the prior written approval
of ADHS/DBHS.
- A Title
XIX eligible person that is receiving services in a Level I residential
treatment center who turns age 21 may continue to receive services
until the point in time in which services are no longer required
or the person turns age 22, whichever comes first.
- Prior authorization
criteria may not include any one of the following as a sole criteria
for denial of services:
- Lack
of family involvement;
- Presence
or absence of a particular mental health diagnosis; or
- Presence
of substance use, abuse or dependence.
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3.14.6
Definitions
Adult
Clinical Team
Behavioral
Health Professional
Certification
of Need (CON)
Child
and Family Team
Clinical Teams
Denial
Emergency
Behavioral Health Services
Inpatient
Services
Level
I Facility
Level
II Facility
Medically
Necessary Covered Services
Prior
authorization
Post
Stabilization Services
Prudent
Layperson
Psychiatric
Acute Hospital
Recertification
of Need (RON)
Residential
Treatment Center (RTC)
Sub-Acute
Facility
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3.14.7
Procedures
3.14.7-A.
Securing services that do not require prior authorization
Who can secure behavioral health services that do not
require prior authorization?
The clinical team
is responsible for identifying and securing the service needs of
each behavioral health recipient through the assessment and service
planning processes. In fulfilling this responsibility, the clinical
team should focus on identifying the underlying needs of the behavioral
health recipient, including the type, intensity and frequency of
supports needed, rather than identifying pre-determined specific
services.
As part of the
service planning process, it is the clinical team’s responsibility
to identify available resources for service provision. The Gila
River RBHA Clinician is responsible for assisting the clinical team in identifying
the most appropriate provider for services. This is done in conjunction
with the entire clinical team including the behavioral health recipient,
family, and significant others involved in the person’s service
planning. The clinical team seeks consultation from others (e.g.
supervisor, Gila River RBHA Clinical Manager) if assistance is needed
in identifying service providers. If the service is available through
a contracted provider the person can access the service directly.
If the requested service is only available through a non-contracted
provider or if a clinical team requests services from a non-contracted
provider, the Gila River RBHA Clinician is responsible for coordinating with
the Gila River RBHA Clinical Manager and Network Manager and obtaining
the requested service as outlined below.
How can
services with a non-contracted provider be secured?
Sometimes it may be necessary to secure services through a non-contracted
provider in order to provide a needed covered behavioral health
service or to fulfill a clinical team’s request. The process
for securing services through a non-contracted provider is as follows:
- The Gila
River RBHA Clinician may initiate a single case
agreement with a non-contracted provider with supervisory approval.
The RBHA Clinician may also coordinate with the Network Manager
to pursue a contract with the provider or for assistance in establishing
a single case agreement;
- Payment
to non-contracted providers requires that the provider have an
active AHCCCS Provider ID #;
- Claims for
services provided by non-contracted providers are paid on a fee-for-service
basis through AHCCCS Administration in accordance with Section
6.1, Submitting Claims and Encounters.
In the event
that a request to secure covered services through a non-contracted
provider is denied, notice of the decision must be provided in accordance
with Section 5.1,
Notice Requirements and Appeal Process for Title XIX and/or Title
XXI Eligible Persons, and Section
5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).
What is
the purpose of a utilization review process?
Behavioral health providers may choose to adopt tools, such as service
planning guidelines, to retrospectively review the utilization of
services. The goals of utilization review include:
- Detecting
over and under utilization of services;
- Defining
expected service utilization patterns;
- Facilitating
the examination of clinicians and clinical teams that are effectively
allocating services; and
- Identifying
clinicians and behavioral health providers who could benefit from
technical assistance.
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3.14.7-B:
Accessing services that require prior authorization
What does prior authorization do?
Prior authorization seeks to ensure that persons are treated in
the most appropriate, least restrictive and most cost effective
setting, with sufficient intensity of service and supervision to
safely and adequately treat the person’s behavioral health
condition. When a clinical team initiates a request for a service
requiring prior authorization, the request must immediately be forwarded
to the personnel responsible for making prior authorization decisions.
When is
prior authorization available?
RBHAs or behavioral health providers must have staff available 24
hours a day, seven days a week to receive requests for any service
that requires prior authorization.
What about
emergencies?
Prior authorization must never be applied in an emergency situation.
A retrospective review may be conducted after the person’s
immediate behavioral health needs have been met. If upon review
of the circumstances, the behavioral health service did not meet
admission authorization criteria, payment for the service may be
denied. The test for appropriateness of the request for emergency
services must be whether a prudent layperson, similarly situated,
would have requested such services.
What is
certification of need (CON)?
A CON is a certification made by a physician that inpatient services
are or were needed at the time of the person’s admission.
Although a CON must be submitted prior to a person’s admission
(except in an emergency), a CON is not an authorization tool designed
to approve or deny an inpatient service, rather it is a federally
required attestation by a physician that inpatient services are
or were needed at the time of the person’s admission. The
decision to authorize a service that requires prior authorization
is determined though the application of admission and continued
stay authorization criteria. In the event of an emergency, the CON
must be submitted:
- For persons
age 21 or older, within 72 hours of admission; and
- For persons
under the age of 21, within 14 days of admission.
For a sample
CON form, see
PM
Form 3.14.1.
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What is
re-certification of need (RON)?
A RON is a re-certification made by a physician, nurse practitioner
or physician assistant that inpatient services are still needed
for a person. A RON must be completed at least every 60 days for
a person who is receiving services in a Level I facility. An exception
to the 60-day timeframe exists for inpatient services provided to
persons under the age of 21. The treatment plan (individual plan
of care) for persons under the age of 21 in a Level I facility must
be completed and reviewed every 30 days. The completion and review
of the treatment plan in this circumstance meets the requirement
for the re-certification of need. For a sample RON form, see
PM
Form 3.14.2.
What must
be documented on a CON or RON?
The following documentation is needed on a CON and RON:
- Proper treatment
of the person’s behavioral health condition requires services
on an inpatient basis under the direction of a physician;
- The service
can reasonably be expected to improve the person’s condition
or prevent further regression so that the service will no longer
be needed;
- Outpatient
resources available in the community do not meet the treatment
needs of the person; and
- CONs, a dated
signature by a physician;
- RONs, a dated
signature by a physician, nurse practitioner or physician assistant.
Additional
CON requirements
- If a person
becomes eligible for Title XIX or Title XXI services while receiving
inpatient services, the CON must be completed and submitted to
the Gila River RBHA prior to the authorization of payment.
- For persons
under the age of 21 receiving inpatient psychiatric services:
- Federal
rules set forth additional requirements for completing CONs
when persons under the age of 21 are admitted to, or are receiving
services in a Level I facility. These requirements include
the following:
- For an
individual who is Title XIX/XXI eligible when admitted,
the CON must be completed by the clinical team that is
independent of the facility and must include a physician
who has knowledge of the person’s situation and who is
competent in the diagnosis and treatment of mental
illness, preferably child psychiatry;
- For
emergency admissions, the CON must be completed by the
team responsible for the treatment plan within 14 days of
admission. This team is defined in 42 CFR §441.156 as “an
interdisciplinary team of physicians and other personnel
who are employed by, or provide services to patients in
the facility”; and
- For persons
who are admitted and then become Title XIX or Title XXI
eligible while at the facility, the team responsible for
the treatment plan must complete the CON. The CON must
cover any period of time for which claims for payment are
made.
What criteria
are used to determine whether to approve or deny a service that
requires prior authorization?
For services in a psychiatric acute hospital or a sub-acute facility,
ADHS/DBHS has developed the following criteria to be used by all
T/RBHAs and behavioral health providers:
- ADHS/DBHS
Admission to Psychiatric Acute Hospital or Sub-Acute Facility
Authorization Criteria (PM
Attachment 3.14.1); and
- ADHS/DBHS
Continued Psychiatric Acute Hospital or Sub-Acute Facility Authorization
Criteria (PM
Attachment 3.14.2).
For services
in a residential treatment center for persons under the age of 21,
ADHS/DBHS has developed the following criteria to be used by all
T/RBHAs and behavioral health providers:
ADHS/DBHS conducts
all admission and continued stay reviews for Gila River RBHA members
recommended for admission to OBHL Level I, Level II and Level III
behavioral health residential facilities.
If a denial is issued for admission to a RTC or sub-acute facility, the
T/RBHA is expected to provide a clearly outlined alternative plan.
This may require development of a CFT, if one has not already been
established, or consultation with the CFT. It is expected that the
alternative treatment plan will adequately address the behavioral
health treatment needs of the child and will provide specific
information detailing what services will be provided, where these
services will be provided, and when these services will be available
and what specific behaviors will be addressed by these services. It
is also expected that the alternative treatment plan will include
what crisis situations can be anticipated and how the crises will be
addressed.
What happens
if a person is ready to leave a Level I Facility but an alternative
placement is not available?
If a person receiving inpatient services
no longer requires services on an inpatient basis under the
direction of a physician, but services suitable to meet the person’s
behavioral health needs are not available or the person cannot
return to the person’s residence because of a risk of harm to self
or others, services may continue to be authorized as long as there
is an ongoing, active attempt to secure a suitable discharge
placement or residence in collaboration with the community or other
state agencies as applicable. All such instances shall be logged and
provided to ADHS/DBHS upon request.
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3.14.7-C:
Prior authorization procedures for behavioral health providers contracted
by a RBHA
What services must be prior authorized?
Services requiring prior authorization are:
- Non-emergency
admission to and continued stay in an inpatient facility.
Who makes
prior authorization decisions?
A behavioral health professional is required to prior authorize
services unless it is a decision to deny. A decision to deny must
be made by the RBHA Medical Director or physician designee.
How is prior
authorization applied in an emergency admission?
Prior authorization must never be applied in an emergency situation.
What are the
considerations for denials?
A denial of a request for admission to or continued stay in an inpatient
facility can only be made by the RBHA’s Medical Director or
physician designee after verbal or written collaboration with the
requesting clinician.
For Title XIX/XXI
covered services requested by persons who are Title XIX/XXI eligible
or who have been determined to have a serious mental illness, the
RBHA or provider must provide the person(s) requesting services
with a Notice of Action (see PM
Form 5.1.1) following:
- The denial
or limited authorization of a requested service, including the
type or level of service;
- The reduction,
suspension, or termination of a previously authorized service;
and
- The denial
in whole or in part, of payment for a service (this is the RBHA’s
responsibility).
Notice must
be provided in accordance with Section
5.1, Notice Requirements and Appeal Process for Title XIX and Title
XXI Eligible Persons. Before a final decision to deny
is made, the person’s attending psychiatrist can ask for reconsideration
and present additional information.
The RBHA or
provider must ensure 24-hour access to a delegated psychiatrist
or other physician designee for any denials of inpatient admission.
What documentation
must be submitted to obtain a prior authorization and what are the
timeframes for making a decision?
For requests for admission, [RBHA insert required documentation
here. Required documentation for each prior authorized service must
be described].
Decisions to
prior authorize inpatient admission must be made:
- Within one
hour of the request for psychiatric acute hospital or sub-acute
facility;
- Within 24
hours of the request for a residential treatment center for persons
under the age of 21; and
For requests
for continued stay, [RBHA insert required documentation here]. Requests
for continued stay must be submitted within the following timelines:
[RBHA insert timeframes for submitting required documentation here].
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3.14.7-D:
Prior authorization procedures for behavioral health providers contracted
by a Tribal RBHA
What
services must be prior authorized?
Services requiring prior authorization are:
- Non-emergency
admission to and continued stay in an inpatient facility;
- Admission
and continued stay in a Level II behavioral health residential
facility; and
- Admission
to and continued stay in a Level III behavioral health residential
facility.
Who makes
prior authorization decisions?
A behavioral health professional is required to prior authorize
services unless it is a decision to deny. A decision to deny must
be made by the ADHS/DBHS Medical Director or physician designee.
How is prior
authorization applied in emergency admission?
Prior authorization must never be applied in an emergency situation.
What are
the considerations for denials?
A denial of a request for admission to or continued stay in an inpatient
facility can only be made by the ADHS/DBHS Medical Director or physician
designee after verbal or written collaboration with the requesting
clinician.
For Title XIX/XXI
covered services requested by persons who are Title XIX/XXI eligible
or who have been determined to have a serious mental illness, ADHS/DBHS
must provide the person(s) requesting services with a Notice of
Action (see PM
Form 5.1.1) following:
- The denial
or limited authorization of a requested service, including the
type or level of service;
- The reduction,
suspension, or termination of a previously authorized service;
and
- The denial
in whole or in part, of payment for a service.
Notice must
be provided in accordance with Section
5.1, Notice Requirements and Appeal Process for Title XIX and Title
XXI Eligible Persons. Before a final decision to deny
is made, the person’s attending physician can ask for reconsideration
and present additional information.
Upon denial
of a service requiring prior authorization by the ADHS/DBHS Medical
Director or physician designee, a letter is sent to providers notifying
that the service was denied and the reason(s) for the denial.
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What documentation
must be submitted to obtain a prior authorization and what are the
timeframes for making a decision?
Prior to admission (for requests made Monday through Friday 8:00
a.m. to 5:00 p.m.) or within 24 hours of an admission (for requests
made after 5:00 pm Monday through Friday, on weekends or State holidays)
the following must be submitted to the Arizona Department of Health
Services/Division of Behavioral Health Services/ Bureau of Quality
Management and Evaluation (Facsimile number (602) 364-4697):
Level I:
Level II:
Level III :
Prior authorization
decisions for non-emergency admissions to Level I, Level II, and
Level III facilities will be made within 24 hours of receiving the
request, or if the request is received on a weekend or State holiday,
the decision will be made on the next business day.
Authorization
cannot be provided without all the required documentation. For services
provided after hours, on weekends or on State holidays, prior authorization
must be obtained on the next business day.
A provider may
also telephone the Bureau of Quality Management and Evaluation at
phone (602) 364-4648 or fax (602) 364-4697. After hours (after 5:00 pm Monday
through Friday, on weekends or State holidays) a voice message can
be left at the same number and the call will be returned the next
business day.
Prior authorization
is not required for Non-Title XIX/XXI individuals. If Title XIX
or Title XXI eligibility is determined during the hospitalization,
providers may request a retrospective authorization. For retrospective
authorization to occur, a provider must submit a CON and the person’s
service plan to the Bureau of Quality Management and Evaluation
by the next business day following the person’s Title XIX
or Title XXI eligibility determination.
For requests
for continued stay, the following documentation must be submitted to
the Arizona Department of Health Services/ Division of Behavioral
Health Services/ Bureau of Quality Management and Evaluation
(Facsimile number (602) 364-4697):
Level I:
Level II
Level III:
Requests for
continued stay must be submitted within the following timelines:
- Psychiatric
acute hospital and sub-acute facility: The initial authorization
is valid for 72 hours. A request for continued stay authorization
(PM
Form 3.14.3) must be submitted within the initial
72 hours or, if on a weekend or State holiday, the request for
continued stay authorization must be submitted the next business
day. All subsequent continued stay authorizations must be made
prior to expiration of the last authorization;
- Level
I residential treatment centers: The initial authorization
is valid for 30 days. A request for continued stay authorization
(PM
Form 3.14.3) must be submitted two weeks prior to
the expiration of the current authorization; and
- Level
II facilities: The initial authorization is valid for
60 days. A request for continued stay authorization (PM
Form 3.14.3) must be submitted two weeks prior to
the expiration of the current authorization.
- Level
III facilities: The initial authorization is valid for
60 days. A request for continued stay authorization (PM
Form 3.14.3) must be submitted two weeks prior to
the expiration of the current authorization.
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3.14.7-E:
Prior authorizing medications
RBHAs must obtain approval from the ADHS/DBHS Medical Director
prior to establishing prior authorization for any medication, including
dosage and dispensing restrictions. For specific information on
medications requiring prior authorization, see Section
3.16, Medication Formulary. If a RBHA or behavioral
health provider requires prior authorization for medications, the
following requirements must be met:
- Adherence
to all prior authorization requirements outlined in this section,
including:
- Prior
authorization availability 24 hours a day, seven days a week;
- Assurance
that a person will not experience a gap in access to prescribed
medications due to a change in prior authorization requirements.
RBHAs and behavioral health providers must ensure continuity
of care in cases in which a medication that previously did
not require prior authorization must now be prior authorized;
and
- Incorporation
of notice requirements when medication requiring prior authorization
is denied, suspended or terminated.
3.14.7-F.
Coverage and payment of emergency behavioral health services
The following conditions apply with respect to coverage and payment
of emergency behavioral health services for persons who are Title
XIX or Title XXI eligible:
- Emergency
behavioral health services must be covered and reimbursement made
to providers who furnish the services regardless of whether the
provider has a contract with a T/RBHA;
- Payment must
not be denied when:
- A T/RBHA
or behavioral health provider instructs a person to seek emergency
behavioral health services;
- A person
has had an emergency behavioral health condition, including
cases in which the absence of medical attention would have resulted in:
-
Placing the health of the person (or, with respect to
a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy;
- Serious
impairment to bodily functions; or
- Serious
dysfunction of any bodily organ or part.
- Emergency
behavioral health conditions must not be limited to a list of
diagnoses or symptoms;
- A T/RBHA
may not refuse to cover emergency behavioral health services based
on the failure of a provider to notify the T/RBHA of a person’s
screening and treatment within 10 calendar days of presentation
for emergency services.
- A person
who has an emergency behavioral health condition must not be held
liable for payment of subsequent screening and treatment needed
to diagnose the specific condition or stabilize the person; and
- The attending
emergency physician, or the provider actually treating the person,
is responsible for determining when the person is sufficiently
stabilized for transfer or discharge, and such determination is
binding the T/RBHA.
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The following
conditions apply with respect to coverage and payment of post-stabilization
care services for persons who are Title XIX or Title XXI eligible:
- The T/RBHA
is responsible for ensuring adherence to the following requirements,
even in situations when the function has been delegated to a subcontracted
provider;
- Post-stabilization
care services must be covered without authorization and reimbursement
made to providers that furnish the services regardless of whether
the provider has a contract with a T/RBHA for the following situations:
- Post-stabilization
care services that were pre-authorized by the T/RBHA;
- Post-stabilization
care services that were not pre-authorized by the T/RBHA or
because the T/RBHA did not respond to the treating provider’s
request for pre-approval within one hour after being requested
to approve such care or could not be contacted for pre-approval;
or
- The T/RBHA
and the treating physician cannot reach agreement concerning
the member’s care and a T/RBHA physician is not available
for consultation. In this situation, the T/RBHA must give the
treating physician the opportunity to consult with a contracted
physician and the treating physician may continue with care
of the member until a contracted physician is reached or one
of the following criteria is met:
- A T/RBHA
physician with privileges at the treating hospital assumes
responsibility for the person’s care;
- A T/RBHA
physician assumes responsibility for the person’s care
through transfer;
- The T/RBHA
and the treating physician reach an agreement concerning the
person’s care; or
- The person
is discharged.
3.14
Securing Services and Prior Authorization
Last Revised: 04/27/2006
Effective Date: 08/01/2007
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