ࡱ> ^`]@ "/bjbj.. 0<DD&*((((8` l$(!GNVXXX* & F$oHRJZFFF"""V"V""" `e%}z(""BF0!G"K"K"((K" "FF 14 DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE SERVICES 193 MENTAL HEALTH SERVICES Chapter 40: REVIEW OF REQUESTS FOR SPECIALIZED OUT-OF-STATE MENTAL HEALTH TREATMENT FOR ADULTS Summary: A protocol for preauthorization is established to ensure fair, timely, accountable and cost effective access to specialized out-of-state mental health treatment for adults. Criteria of eligibility for authorization for specialized treatment are established, and the mechanism for requesting preauthorization is delineated. Section 1. Purpose and Scope To remain consistent with the Departments goals of developing a system of care for adults with mental illness in the state of fb88, that is high quality, accountable, cost-effective, fair and client centered, a protocol and criteria for preauthorization of specialized out-of-state mental health treatment have been developed. Requests for specialized out-of-state treatment come from a variety of sources and are directed to staff at every level of the Department. Clients for whom such requests are made may be currently engaged in outpatient treatment, in-patient treatment or no treatment. Therefore, a consistency of approach to make these decisions with clear criteria for authorizing specialized treatment based on medical necessity, best clinical practice, and cost-effectiveness is in the interest of everyone affected by these decisions. Section 2. Criteria for Specialized Out-of-state Treatment Funding 1. Requests for funding specialized out-of-state mental health treatment will be considered only for adult clients of DMHMRSAS, as currently defined. 2. Requests for grant funding specialized out-of-state mental health treatment will only be considered when all other sources of funding have been exhausted (such as reciprocal Medicaid agreements, third party insurance, personal resources, etc.). Every effort must have been made to fund the treatment jointly with other responsible agencies involved. 3. The client must have a current psychiatric evaluation that reports findings of instability secondary to an Axis I major mental illness, as defined by the current edition of the Diagnostic and Statistical Manual. The current clinical picture must clearly demonstrate medical necessity for treatment, as defined by evidence of severe dysfunction in aspects of daily living or danger to self or others, which has existed for at least 6 months or longer. 4. Requests for specialized out-of-state mental health treatment will only be considered when it has been demonstrated that in-state treatment AND treatment at a lower level of care have reasonably been attempted and failed, OR that there is no appropriate, safe and effective treatment available in the state. 5. The specific treatment plan or program being requested must have proven efficacy in the treatment of the clients Axis I diagnosis, be consistent with best clinical practice and qualitatively different from a program available in the state of fb88. Specialized out-of-state treatment will be authorized only when the program and/or facility meets applicable licensing regulations and there is reason to expect the program requested will significantly improve the condition of the client, returning him/her to a former level of stability. At the Departments discretion, a Departmental staff person may be designated to conduct an on-site review of the program being considered. 6. Requests for specialized out-of-state treatment will be approved only when it can be demonstrated that without the requested treatment, the client will continue to be unstable or will deteriorate further. 7. The client must voluntarily accept the specialized out-of-state treatment and evidence some capacity to benefit from the treatment. The guardian, if applicable, must also approve the specialized out-of-state treatment plan. 8. The specialized out-of-state treatment plan must be cost effective, demonstrated by the reasonable expectation for reduced future behavioral or somatic medical care costs AND by favorable cost comparison to other similar treatments. 9. Every preauthorization of specialized out-of-state treatment shall be for a specific length of time. The clients clinical progress will be monitored during treatment, consistent with good utilization review practices. When it is clinically appropriate, or if the clients condition does not improve in a reasonable period of time, the authorization for continued treatment may be withdrawn and the client transferred to a less intensive level of care or an instate program. Such a withdrawal and transfer will be done with sufficient notice to the client, family and providers involved. 10. Before preauthorization will be granted, there must be a preliminary discharge or transition plan developed, for the client to return to an instate treatment program. Section 3. Procedures 1. Notwithstanding any other provisions herein, DMHMRSAS shall act on applications for prior authorization for specialized out-of-state services with reasonable promptness and shall adjust the time periods specified herein as circumstances require in order to do so. In cases of an emergency, the prior authorization process will be completed as expeditiously under the circumstances as necessary to alleviate the emergency. 2. All requests for Departmental funding for specialized out-of-state mental health treatment shall be directed to the appropriate Regional Mental Health Team Leader. All requests for funding in excess of $5000 must be accompanied by the completed application form and substantiating documentation to demonstrate eligibility as described in Section 2, above. The Team Leader, who will function as coordinator for processing the request, will review the request for completeness and will notify the party making the request, within three (3) working days of receipt, that it is complete or that specific information is missing. For purposes of the foregoing, an application transferred from the Department of Human Services (DHS) shall be deemed received three (3) working days after the referral is sent by DHS to DMHMRSAS. Such transfer shall be accompanied with a notice of the transfer to the applicant and the provider, such notice being sent by DHS in the form of a denial letter, together with the name and telephone number of the contact person at DMHMRSAS (the Team Leader) who will be responsible for processing the application. For purposes of this Protocol and any application form implementing it, an application shall be deemed complete if the attending physician addresses each of the criteria with an opinion accompanied by a reasonable amount of supporting information. 3. The applicant shall make a reasonable effort to submit to DMHMRSAS the information requested within thirty (30) calendar days from the date that notice is received that the application is incomplete, failing which the application may be considered abandoned. Any notice that an application is incomplete sent out by DMHMRSAS more than thirty (30) calendar days from the date the original application was filed or deemed filed with DMHMRSAS shall be considered an adverse action by DMHMRSAS and shall be accompanied with a statement advising the applicant of an opportunity for a fair hearing to challenge the determination that the application is incomplete. In the case of a notice of incompleteness given more than sixty (60) calendar days from the date the original application was filed or deemed filed, the statement shall advise the applicant of an opportunity for a fair hearing to determine not only whether the application is complete, but, in the event it is deemed so, whether DMHMRSAS should be ordered to take final action on the application within ten (10 ) calendar days. Any such order by the fair hearing officer shall provide that the request shall be considered authorized if a decision is not made within such ten (10) day period. Any denial of requested services, in whole or in part, shall be accompanied by a statement advising the applicant of a right to a fair hearing. If an applicant chooses to request a hearing, the request shall be made no later than thirty (30) calendar days from the date of receipt of the notice and DMHMRSAS shall forward such requests to the fb88 Department of Labor Division of Administrative Hearings (or its successor) within 24 regular business hours (that is, by the next working day) and a hearing shall be held within 7 working days thereafter. 4. When the Team Leader determines that the request is complete, the Team Leader will convene a team which shall include at minimum the regional Medical Director and the Regional Director to review the documentation and make a recommendation about the appropriateness of the request for funding. This recommendation will be completed within two weeks of the notification to the party making the request that the application is complete. 5. Once the request has been approved on the regional level, the Team Leader shall forward a written recommendation to the Associate Commissioner for Operations (or designee) with completed application form and supporting documentation for consideration. 6. The Associate Commissioner (or designee) shall make a final determination within two weeks of receipt of the regional recommendation. The determination shall include specific length of stay and terms for concurrent review of treatment progress. 7. Requests for approval of funding for specialized out-of-state treatment shall be finally acted upon within four (4) calendar weeks of the date the application is complete or determined as a result of a fair hearing to be complete. Applications still pending after this four (4) calendar week period shall be deemed approved. 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