1. society
2. welfare
3. healthcare

P r o v id e r M a n u a l
2 0 1 3 -2 0 1 4
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INDEX
Introduction
…………………………………………………………………….……….… 5
……………………………………………...……… 6
APS Healthcare Puerto Rico, Inc.
……………………………………………….… 6
Member Rights and Responsibilities
MEMBER RIGHTS
……………………………………………………………….… 6
MEMBER RESPONSIBILITIES
Provider Operations
…………………………………………………... 8
……………………………………………………………………… 9
PROVIDER STANDARDS
………………………………………………………… 9
FACILITY STANDARDS
……………………………………………………….… 11
SERVICE STANDARDS
……………………………………………………….… 12
ON-CALL COVERAGE
………………………………………………………...… 14
CREDENTIALING/RECREDENTIALING
PROVIDER APPEAL RIGHTS
PROVIDER EDUCATION
……………………………………… 15
………………………………………………..… 19
……………………………………………………..… 20
ON SITE EVALUATION PROCESS
TREATMENT RECORD REVIEW
………………………………………….… 21
……………………………………………… 22
TREATMENT DOCUMENTATION GUIDELINES
Utilization Management
…………………………….. 22
………………………………………………………………… 24
CLINICAL PROCEDURES
…………………………………………………….… 26
CLINICAL PRACTICE GUIDELINES
………………………………………...… 31
INTRODUCCTION TO APS-PR HEALTHCARE MEDICAL
NECESSITY AND LEVEL OF CARE DETERMINATION CRITERIA
DEFINITIONS FOR LEVELS OF CARE
23-HOURS OBSERVATION
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……..... 31
………………………………………... 32
……………………………………………………... 34
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INPATIENT (ACUTE CARE)
………………………………………………….… 34
INPATIENT DETOXIFICATION
………………………………………………… 35
INPATIENT REHABILITATION
……………………………………………….… 36
PARTIAL HOSPITALIZATION- PSYCHIATRIC CARE:
(ADULT, CHILD/ADOLESCENT) ……………………………………………..… 37
PARTIAL HOSPITALIZATION- SUBSTANCE DEPENDENCE:
(ADULT/ADOLESCENT) ………………………………………………………… 38
OUTPATIENT DETOXIFICATION
(AMBULATORY DETOXIFICATION)
………………………………………...… 39
INTENSIVE OUTPATIENT THERAPY PSYCHIATRIC CARE:
(ADULT, CHILD/ADOLESCENT) ……………………………………………..… 40
INTENSIVE
OUTPATIENT
THERAPY
SUBSTANCE
DEPENDENCE:
(ADULT/ADOLESCENT) ………………………………………………………… 41
OUTPATIENT CARE
…………………………………………………………..… 42
RESIDENTIAL TREATMENT (RTC, DOMICILIARY CARE)
PSYCHIATRIC CARE: (CHILD/ADOLESCENT) ……………………………... 43
RESIDENTIAL TREATMENT (RTC, DOMICILIARY CARE)
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT) …………………… 44
METHADONE MAINTENANCE
………………………………………………… 46
ELECTROCONVULSIVE THERAPY (ECT)
PSYCHOLOGICAL TESTING
…………………………………… 47
………………………………………………...… 48
ADVERSE DETERMINATION AND APPEALS PROCESS
REPORTING ADVERSE OCCURRANCES
ANCILLARY SERVICES
……………….… 49
…………………………………… 49
……………………………………………………….… 50
MIXED PSYCHIATRIC/MEDICAL PROTOCOL
……………………………… 50
Customer Service ……………………………………………………………………..… 51
TERMINATED MEMBERS
……………………………………………………… 51
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GRIEVANCE SYSTEM
…………………...……………………………………… 52
RETROSPECTIVE-REVIEW
Claims Department
………………………………………………….… 56
……………………………………………………………………… 57
CLAIMS QUALITY MEASUREMENT PROGRAM
REIMBURSEMENT PROCEDURES
…………………………………………… 58
MEMBER HOLD HARMLESS PROVISION
Quality Improvement Program
PURPOSE AND GOALS
………………………….… 57
…………………………………… 62
……………………………………………………...… 63
……………………………………………………….… 63
STRUCTURE OF THE QUALITY IMPROVEMENT PROGRAM
PROGRAM SCOPE AND CONTENT
………………………………………..… 72
RESOURCES DEDICATED TO QUALITY IMPROVEMENT
CONFIDENTIALITY
……………….. 79
………………………………………………………………. 81
EVALUATION AND UPDATE
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………….… 63
…………………………………………………… 81
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INTRODUCTION
Welcome to APS Healthcare Puerto Rico, Inc.
As a Participating Provider, you join a select network of facilities and treatment
programs working with an innovative managed behavioral health organization. APS-PR
has developed a provider network to help increase the effectiveness and promote the
rational use of mental health and chemical dependency resources.
In close
collaboration with our participating provider network, such processes as case
management, quality assurance and utilization review, help ensure that our services will
safeguard quality while managing costs.
This Provider Manual was developed to answer your questions and to serve as a
reference source for your office staff. While many questions will be addressed by this
guide, please feel free to contact our Provider Relations Department for additional
assistance at 1-800-503-7929 X 2742.
From time to time it may be necessary to update this Manual. You will receive
replacement sections with explanations of changes, additions or deletions. Periodically
you will also receive APS Healthcare Puerto Rico, Inc. informational communications
and Provider Newsletters.
APS-PR provides a partnership with you which offers referrals and prompt
reimbursement for your services. The information contained herein is applicable to all
network providers; however, authorization and claims-submission procedures vary by
customer. Please refer to the member’s identification card to determine authorization
and claims payment procedures.
QUESTIONS OR COMMENTS
Specific policy or procedural questions which are not addressed in this manual may be
directed to the Provider Relations Department of APS Healthcare Puerto Rico, Inc.
Comments or questions regarding the Provider Manual itself should be directed to:
APS Healthcare Puerto Rico, Inc.
Provider Relations Department
P.O. Box 71474
San Juan, P.R. 00936-8574
Phone: 1 (800) 503-7929
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APS HEALTHCARE PUERTO RICO, INC.
As a managed behavioral healthcare company, APS-PR has the expertise to provide:
administrative, consultative and case management services to our providers and
members.
APS-PR offers twenty-four (24) hour on call service for Members and Providers by
trained and experienced professionals. Assessment and referral services are provided
to the most appropriate and available level of care. A multi-disciplinary team approach
is used. Psychiatric nurses (RN), master’s level social workers (MSW), or psychologists
conduct patient interviews telephonically and review treatments for providers delivering
clinical services. Psychiatrists are on staff and available for consultation whenever
necessary. Treatment planning with our clinical care managers is coordinated with our
providers from initial assessment and throughout treatment.
We believe that the relationship between treatment standards and clinical judgment is
one of assistance and collaboration rather than one of control. The intent of treatment
standards is to inform clinical judgment, not to overrule the clinician’s professional
experience.
However, in an effort to have consistency in the clinical decision making process, APSPR has formulated a set of clinical guidelines upon which our clinicians base their
decisions. The clinical criteria are based upon reasonable scientific evidence in the field
of behavioral healthcare and are contained under section III under APS-PR Utilization
Management criteria. To obtain an additional set of the APS Healthcare Puerto Rico,
Inc. clinical criteria, please call (800) 503-7929 ext. 3027.
[ I ] Member Rights and Responsibilities
APS-PR providers should be familiar with the APS-PR Members Rights and
Responsibilities Statement. A copy of these should either be displayed in your office or
given to the member prior to your rendering any services.
A. MEMBER RIGHTS
1. Members have the right to be provided care and treatment with dignity and respect;
as individuals who have personal needs, feelings, preferences and requirements.
2. Members have the right to impartial services and access to treatment, regardless of
race, religion, gender, ethnicity, age, or disability.
3. Members have the right to privacy in their treatment, in their care and in fulfillment of
their personal needs.
4. Members have the right to be treated by staff/providers who communicate in a
language/format they understand.
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5. Members have the right to be fully informed of all services available, any charges for
or limitations to those services and available alternative treatment.
6. Members have the right to be provided an individualized treatment plan and to
participate in decision making regarding their treatment planning.
7. Members have the right to be fully informed, in a language/format they understand,
of their rights as clients and of all rules and regulations governing their conduct as
clients in this program.
8. Members have the right to be fully informed of all diagnostic and/or treatment
procedures, medication treatments, including the benefits and risks, any research
projects involving their treatment through APS-PR and to receive information
necessary to give informed consent prior to the start of any procedures, treatment or
research project.
9. Members have the right to a candid discussion of appropriate or medically
necessary treatment options for their conditions. Members have the right to know
treatment options regardless of the cost and whether they are covered services.
10. Members have the right to refuse treatment without compromising their access to
the organization’s services to the extent permitted by law, and to be informed of the
consequences of this refusal. However, the provider reserves the right to
discontinue treatment should the extent of their refusal make reasonable and
responsible treatment possible.
11. Members have the right to continuity of care. As long as they remain eligible for
services through APS-PR, members will not be discharged or transferred except for
therapeutic reasons, for their personal welfare, or for the welfare of others. Should
their transfer or discharge become necessary, members will be given the reasons
and plan, as well as reasonable advance notice, unless an emergency situation
exists.
12. Members have the right to voice opinions, recommendations, complaints, or appeals
in relation to APS-PR policies, members’ rights and responsibilities or the care
provided without fear of restraint, interference, coercion, discrimination, or reprisal.
13. Members have the right to be free from physical, chemical and mental abuse.
14. Members have the right to confidentiality management of their medical records as
established by HIPAA Law.
15. Members have the right to refuse to perform any services for the program, or for
other clients, unless they are a part of their therapeutic plan of treatment, which they
have approved.
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16. Members have the right to be informed in advance of any non-staff visitors to a
facility/office and the right to privacy if they do not wish to see visitors, or participate
in activities while visitors are present.
17. Members have the right to receive information necessary to give informed consent
prior to being involved in activities, which include the use of tape recorders, video
tape equipment, one-way observation mirrors, photography, or any other techniques.
18. Members have the right to receive information regarding the authorization and
certification /non-certification processes, benefit plan services included and
excluded; co-payments; the provider network available for their care at the time they
seek to access care; clinical guidelines, members rights and responsibilities; and
how to file a claim.
19. Members have the right to file an appeal for review by an individual uninvolved in the
original determination.
B. MEMBER RESPONSIBILITIES
1. Members have the responsibility to provide, to the extent possible, information that
APS-PR and its providers need in order to care for them.
2. Members have a responsibility to follow the plans and instructions for care that they
have agreed upon with their provider(s).
3. Members have the responsibility to follow administrative guidelines and codes of
conduct in the provider facility.
4. Members have the responsibility to attend appointments free from the influence of
alcohol and illegal substances.
5. Members have a responsibility to participate, to the degree possible, in
understanding their behavioral health problems and developing mutually agreedupon treatment goals.
6. Members have a responsibility to follow APS-PR policies and processes as
described in their handbook/packet regarding authorization and certification/noncertification; benefit plan eligibility; benefit plan services included and excluded; copayments; the provider network available to them and how to file a claim.
[ II ] PROVIDER OPERATIONS
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The Provider Operations Area, operating through its Provider Relations Department,
acts as a liaison between all participating providers (PCPs, Specialists, Hospitals, and
Ancillary Services), and the departments within the organization.
The Provider Operations Area is made up of a team of approximately six managed care
professionals supervised by the Provider Relations Manager. This person is directly
responsible for supervising the daily operations for the department. These processes
include: Recruitment, Servicing, Credentialing and Re-credentialing among others.
Provider Operations are dedicated to assist APS-PR providers with the following:
*
*
*
*
*
*
*
*
*
Orientation of new APS-PR providers and their staff
Education of APS-PR providers regarding policies and procedures
Conducting Site Visits
Producing and distributing provider newsletters
Resolving problems for providers
Contracting providers
Network development
Recruitment of specialized providers
Working with providers in the development and implementation of financial
reviews and effective referral patterns.
A. PROVIDER STANDARDS
1. Access Standards
When APS-PR contacts a provider with a referral or a member in ongoing treatment
calls a provider to schedule an appointment, it is expected that the provider will be able
to offer an appointment to the member within APS-PR standards of accessibility.
The following scheduling standards supersede all lesser scheduling standards in the
provider agreement:
2. Emergent Care
APS-PR has divided emergent care into two types: life-threatening and non-lifethreatening. When a member presents with a life-threatening emergency they should
be seen immediately. Members who present with a non-life-threatening emergency
should be offered an appointment within six (6) hours of contact.
Life-threatening Emergent Care is required when a member has made a suicide attempt
or is in immediate danger of making a suicide or homicide attempt. It may be
appropriate for the member to be treated in the Emergency Room of a hospital on those
occasions. Non-life threatening Emergent Care applies to those situations when the
patient is markedly distressed, has limited resources, and when there is a strong
potential for rapid instability.
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3. Urgent Care
Urgent care is required when a member is markedly distressed but has the resources to
avoid imminent instability. It also pertains to members being discharged from the
inpatient, partial day hospital, or intensive outpatient levels of care. When a member
requires urgent care an appointment should be offered within twenty four (24) hours of
contact.
4. Routine Care
An appointment is to be offered within five (5) business days of the initial referral for
routine care.
When accepting referrals, providers should be able to schedule ongoing appointments
in a timely manner. Every attempt should be made to accommodate members within
these access standards. It is important that the provider document the first appointment
offered, specially when the member fits either the emergent or urgent criteria or refuses
appointments that fall within the APS-PR access standards. If a provider is unable to
meet these standards, the provider is to notify APS-PR so that alternative arrangements
can be made. Any provider who is consistently unable to schedule appointments within
the time frames described above will be presented to APS-PR’s Credentialing
Committee for review and action.
When a member contacts his or her provider by telephone for any reason, it is expected
that the provider or an office administrator will return the member’s call promptly.
Emergent phone calls are to be returned within thirty (30) minutes. Urgent calls are to
be returned within one (1) hour. Routine calls are to be returned by the next business
day.
APS-PR network providers are responsible for the ongoing care of any member for
whom a referral has been accepted. It is expected that answering machine
messages and answering services provide patients with a number to contact the
provider in the case of an emergency. A message that states that the patient
should go to the Emergency Room of a hospital is not acceptable. If on-call
responsibilities are rotated in a group practice or with clinicians who do not participate
with APS-PR, it is the responsibility of the primary clinician to see that APS-PR’s referral
and authorization procedures are followed.
5. New Patients/Clients
A) Please remember that you must accept new referrals from APS-PR on the same
basis as you are accepting non-APS-PR members; without regard to race, religion,
gender, color, sexual orientation, place of residence, national origin, age or physical
or mental health status.
B)
The only times you may refuse a APS-PR referral are:
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•
•
The patient requires treatment that is outside the scope of your clinical licensure
or expertise.
Your panel is closed to all new patients.
Note: If you decide to stop accepting any new patients, you must give APS-PR 30 days
advance notice in writing.
6. Preferential Turns
As an APS provider you are expected to establish a system of preferential turns, regardless of your specialty- that allow residents of the island municipalities of Vieques
and Culebra. A system of preferential turns refers to a policy that you as a provider
must establish in order to give priority in treating enrollees from the islands of Vieques
and Culebra, so they may be seen by a provider within a reasonable time after arriving
in the Provider’s office. The priority in turns given to these enrollees is necessary due to
their remote place of residence and the increased length of time required in getting back
to those island municipalities. All providers must be aware that this is a requirement
established by Articles 1-4 of the Law No. 86 of August 16, 1997 and Articles 1-5 of Law
No. 200 of August 5, 2004.
7. Report Requirements
Provider must comply with reporting requirements as established by ASES and APSPR, and particularly with the requirements to submit Encounter Data, Claims Data, UM
Data, for all services provided, and to report all instances of suspected Fraud and
Abuse among others. All reports submitted by Provider to APS-PR have to be labeled
with the Provider’s NPI. Reports Other reports may be required by APS-PR as needed
according with the terms of the provider contract or the contract between APS-PR and
the ASES.
B. FACILITY STANDARDS
Our facility standards refer to the inpatient and outpatient sites where members receive
services. These standards address the appearance, safety and licensure, if applicable,
of the office or facility. The following standards are required of APS-PR facility
providers:
•
•
•
•
•
•
•
Visible signs clearly identify the facility;
The exterior of the building is clean and well maintained;
Parking is adequate and nearby;
The area surrounding the facility is safe when exiting at night;
The waiting room has adequate seating for patients;
The facility is clean and in good repair (this includes the waiting room, admission
area, patient rooms and halls, offices, kitchen, dining area, rest rooms and common
areas);
The facility meets the requirements of the Americans with Disabilities Act (ADA);
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•
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Emergency phone numbers (police, fire, ambulance) are posted in common staff
areas;
Fire extinguishers are readily available;
Smoking is restricted to an outdoor location or a separately ventilated room;
Medications are protected from public access;
All hospital units and inpatient and outpatient programs are licensed by the state;
If eligible, the hospital or facility is accredited by the Joint Commission for the
Accreditation of Health Care Organizations (JCAHO);
If sanctioned by JCAHO, the provider has submitted an acceptable corrective action
plan;
If eligible, the provider is Medicare approved;
If eligible, the provider is Medicaid approved.
C. SERVICE STANDARDS
1. The following service standards apply to all providers:
•
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•
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•
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•
There is at least one staff member available for patient intake during business hours;
Routine phone calls from patients are returned by the next business day;
Urgent calls from patients are returned within one (1) hour;
Emergent calls from patients are returned within thirty (30) minutes;
The provider informs all patients on how the provider is to be contacted during and
after business hours in an urgent or emergent situation;
Unless the situation is life threatening, patients are not directed to go to an
emergency room;
Routine initial outpatient appointments are scheduled within five (5) business days of
receiving a referral;
Urgent outpatient appointments are scheduled within twenty four (24) hours of the
referral or contact from a member in ongoing treatment;
Emergency outpatient appointments are scheduled immediately if the patient has a
life-threatening emergency or within six (6) hours of the referral or contact from a
member in non-life-threatening emergencies;
Providers are trained in de-escalation techniques;
Patient education materials are distributed routinely;
Providers are encouraged to receive training in brief therapy;
Providers are trained and/or experienced in working effectively with Managed
Behavioral Health Care Organizations;
HMO Members can be charged an amount when an appointment is canceled with
less than twenty-four (24) hours notice or when the member fails to provide any
notice as establish by the Office of the Health Advocate (Oficina del Procurador de
la Salud); this is not applicable to Medicaid Eligible Persons enrolled in MISalud;
Release of information to the member’s Primary Care Physician (PCP) as part of the
intake process, if applicable;
Member Rights and Responsibilities statement is displayed or distributed to the
member prior to rendering service.
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2. The following service standards apply only to those providers contracted with
APS-PR to provide inpatient, residential, partial hospitalization, intensive
outpatient services or twenty-three (23) hours evaluation and observation
services:
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•
•
•
•
•
•
•
•
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•
Visitors are required to sign a confidentiality statement prior to entering patient
areas;
Provider adheres to written admission criteria;
If services are not provided in a general hospital, arrangements are in place for
transporting patients in the case of a medical emergency;
Examination rooms are available to perform the case history and physical
examination of patients;
Crash carts or emergency boxes are available for the medical emergencies;
Clinical staff to patient ratio are adequate;
Staff is trained annually in de-escalation techniques;
Treatment is individually tailored to meet the needs of each patient;
Adult and adolescent patients are separated by units or by patient rooms;
Adolescent and child patients are separated by units or by patient rooms;
The Initial Treatment Plan is completed within twelve (12) hours of admission;
The case history and physical examination of the patients are completed within
twenty-four (24) hours of admission;
The Psychosocial Assessment is completed within twenty-four (24) hours of
admission;
The Initial Psychiatric Assessment including Mental Status Exam and DSM-IV
diagnosis is completed within twelve (12) hours of admission;
Discharge planning begins upon admission and includes scheduling a postdischarge outpatient appointment within forty-eight (48) hours of discharge.
3. The following service standards apply to hospitals and programs with acute
mental health units only:
•
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•
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•
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•
Patients are seen by an MD at least once within any 24 hour period.
Admissions are accepted twenty-four (24) hours per day, seven (7) days per week;
Acute units are locked;
All hallways can be monitored from the nursing station(s) directly or with the use of
video equipment;
Patients do not have access to potentially harmful objects;
Shower heads are recessed or do not bear weight (suicide-proof);
Patient rooms are free from any weight-bearing objects;
Patient rooms are free of electrical cords that are twelve (12) inches or longer in
length;
Medically complex patients who are at-risk for suicide and are in rooms that require
electrical cords are monitored at least every fifteen (15) minutes;
Light fixtures are recessed or are protected by a non-breakable device;
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•
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•
•
•
Windows and mirrors are shatterproof or protected by a non-breakable device;
All objects within the seclusion room are secured;
One piece toilet seats are used in the seclusion area rest room;
Patients in seclusion and in the adjacent bathroom can be viewed by staff at all
times;
Staff is trained annually in the use of de-escalation techniques to avoid the use of
seclusion unless absolutely necessary.
4. The following service standards apply to only those hospitals and programs
who provide substance abuse services:
•
•
•
•
•
•
Patients are seen at least once within any 24 hour period.
If provided, admissions for medical detoxification are accepted twenty-four (24)
hours per day, seven (7) days per week;
Beds dedicated to patients admitted for detoxification are nearest to the nursing
station;
Staff includes providers with substance abuse certification;
Urine/drug screens are conducted routinely;
An aftercare or APS-PR prevention program is offered to all patients for a period of
at least six (6) months.
D. ON-CALL COVERAGE
1. Covering Providers
If a provider is temporarily unavailable to members who are in active treatment, the
provider is responsible for arranging adequate emergency coverage during the
provider’s absence. APS-PR must be notified of all coverage arrangements. Covering
providers must adhere to all of APS-PR’s administrative requirements, including, but not
limited to: authorization procedures, accessibility standards and co-payment collection.
The covering provider must be of equivalent licensure level and must accept APS-PR’s
fee schedule allowance.
When arranging emergency coverage, network providers are not required to work with a
participating APS-PR provider but it is suggested. If the provider who is covering is not
participating with APS-PR, the APS-PR provider is responsible for obtaining
authorization for coverage from APS-PR. All claims generated by the covering provider
should include the authorization number and should indicate the provider for whom
services are being covered. Payment for claims submitted without this documentation
will be denied.
2. Suspending Referrals
When a provider is temporarily unable to schedule initial appointments within five (5)
business days or if the provider is unable to accept new referrals due to a leave of
absence, vacation or any other reason, the provider is to notify APS-PR in writing. A
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letter stating the reason for the provider’s inability to accept referrals and the time frame
during which referrals are to be suspended should be submitted to the attention of the
Provider Relations Department.
E. CREDENTIALING/RECREDENTIALING
1. Initial Credentialing
All prospective providers undergo an evaluation of their professional credentials and
experience. The purpose of the credentialing process is to ensure that all APS-PR
providers meet the criteria established by the APS-PR Credentialing Committee. The
credentialing process also ensures compliance with the guidelines established by the
National Committee for Quality Assurance (NCQA) and Center for Medicare and
Medicaid Services (CMS).
The credentialing process is initiated with the submission of a signed agreement and a
complete application to APS-PR.
The application is carefully reviewed for
completeness and adherence to the APS-PR credentialing criteria.
Accepted
applications with supporting documents are submitted for primary source verification
and then forwarded to the APS-PR Credentialing Committee for peer review and
disposition. All applicants are informed in writing of acceptance into or rejection from
the APS-PR network.
The Credentialing Committee is chaired by the Medical Director and also includes
network providers in order to provide peer review. If you are interested in joining the
committee, please call us.
2. Primary Source Verification
Choosing the practitioners who will work well in the delivery system is the responsibility
of APS-PR. Well-defined policies and procedures describe the requirements and the
process used to evaluate practitioners.
(a) Application reviewed for completeness. Any application more than one hundred and
eighty (180) days beyond the signature date requires a current signature to confirm
that all the information remains accurate and correct.
(b) License Verification through the appropriate state licensing board is either written or
oral.
(c) Liability Insurance; Must be active and meet minimum coverage required (1 million/3
million for Hospitals, Programs, Agencies, M.D. and D.O. Ph.D. and MSW level
requires 1 million/1 million coverage). Additional verification is required only if there
is a positive history in the past five (5) years of claims or sanctions.
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(d) Positive history of claims requires written explanation from the provider to be
reviewed by the Area Credentialing Committee.
(e) Hospital Privileges: Verified in writing through Privilege Verification Form (Required
for MD and DO).
(f) Board Certification: Copy of entry into ABMS compendium.
(g) If not Board Certified then residency must be verified in writing with verification of
residency form.
(h) Education verified at highest level, attained orally with the University or in writing.
For MD and DO this is not required if Board Certified or if the residency is verified.
(i) A copy of a valid DEA or CDS certificate (if applicable).
(j) National Provider Data Bank (NPDB) inquiry queried for all providers. If there are
any loss of privileges, malpractice history or other sanctions found they will be
reviewed on a case by case basis by the Area Credentialing Committee.
(k) Medicare/Medicaid Sanctions after 3/3/97 are queried by virtue of NPDB.
(l) Provider is reviewed by the APS-PR Credentialing Committee for final approval.
(m)Educational Commission for Foreign Medical Graduates (ECFMG) must be included
for Foreign Graduates.
(n) Curriculum Vitae: The last five years must be documented and APS-PR explained.
The credentialing specialist will notify the applicant of missing data elements and secure
the required information. If the credentialing specialist is unable to secure the required
information within a predetermined time, the credentialing process will cease and the
applicant will be notified in writing of the action with cause.
Confirmation of primary source verification is expected to be submitted to the
Credentialing Committee in sixty (60) days for US educated/trained providers and ninety
(90) days for foreign educated/trained providers following receipt of a completed
application and supporting documents. A portfolio with copies of the supporting
documents of each applicant will be submitted to APS-PR Credentialing Committee.
3. Re-credentialing
As a participating provider, you will undergo a triennial (every 3 years) re-examination of
your credentials. The process will be initiated six months (6) prior to the anniversary
date of the contract or employment. The re-examination of your credentials will be
combined with an objective evaluation of your history with APS-PR related to:
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(a) Delivery of Quality Care that is congruent with APS-PR’ philosophy and treatment
protocols.
(b) Participation in Quality Improvement activities
(c) Utilization Management (compliance and track record)
(d) Patient Satisfaction (survey results and complaint tracking)
(e) Medical Records (meeting objective criteria for completeness and legibility)
(f) Results of office site visits.
(g) Quality of Care Issues
(h) Complaints and Grievances history
All of the above described information will be reviewed by the Credentialing Committee
who will decide whether participation in the APS-PR network will be continued. You will
be notified in writing of the decisions of the committee. If the re-credentialing process is
not completed within 3 years, you will be terminated from the network and will need to
apply to APS-PR as a new provider.
4. Quality Reviews
In addition to the normal re-credentialing cycle, providers may be reviewed between
cycles when quality performance monitors indicate the need for such a review. APS-PR
monitors the quality of provider services by tracking complaints received from members,
clients, organizations or APS-PR staff. Complaints are weighted according to the
seriousness of the complaint or by the number of less serious complaints received. In all
cases, a Provider Relations staff member will contact provider to gain additional
information about the content of the complaint before a weight is assigned.
In most instances, APS-PR will work with the provider to either educate them in cases
where lack of knowledge on the part of the provider led to the complaints, or to develop
an Action Plan with the provider to bring them into compliance.
In certain instances when, either because of the number of complaints or the
seriousness of the complaint, the provider file will be reviewed by the Credentialing
Committee who will make recommendations regarding the network status of the
provider as well as regarding actions to be taken by APS-PR. A provider may be
suspended or terminated from the network as a result of the review of the Credentialing
Committee. Possible actions which can be taken by APS-PR include, but are not limited
to a Site Visit of the practitioner, a Treatment Record review of APS-PR members in
treatment with practitioner, contact by the APS-PR Medical Director or his/her delegate
to further discuss the issues, suspension or termination from the network.
5. Additional Events Causing Early Termination or Suspension:
Not withstanding any other provision in the Provider Service Agreement, The
Credentialing Committee may terminate a provider’s credentialing status at any time
upon notice to the Physician of the occurrence of any of the following events;
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(a) Provider’s conviction of a felony or misdemeanor or involving moral turpitude.
(b) Professional incompetence of Provider, or non-performance of professional
responsibility.
(c) Provider’s failure to comply with quality improvement and utilization review
procedure and standards, as established by APS-PR, including, but not limited to,
appointment availability, billing practices, utilization, provision of services, cost
effective use of inpatient services unless adequately justified as determined by APSPR surveys or outcome studies and failure to meet timeline requirements of the
credentialing program.
(d) Provider’s physical disability resulting from alcohol or drug abuse, which impairs
physician’s ability to practice his or her profession in a competent manner; or loss or
suspension of the licenses required to fulfill the Agreement.
(e) Provider’s failure to maintain membership on the Medical Staff of his/her primary
admitting facility or failure to maintain adequate malpractice or general liability
insurance.
(f) Provider’s failure to provide satisfactory personal and professional references and
credentials, or to provide verifiable information regarding past employment, training,
hospital affiliation, or professional licensing for him/herself or any paraprofessional
under his/her supervision.
(g) Provider being a party to or having been a party to malpractice or other litigation or
arbitration that has resulted in material judgments, settlements or awards against
Physician.
(h) Provider’s solicitation of Member’s during the initial and any succeeding term of the
Agreement, or knowingly or directly advising any APS-PR Member to become
enrolled with any other Health Maintenance Organization, Physician Organization, or
any other similar hospitalization or medical payment plan or insurance program.
(i) APS-PR’s inability to maintain agreements with hospitals, physicians, and ancillary
service providers who collectively constitute a service delivery system, or the loss of
business in the provider’s service area.
APS-PR reserves the right to suspend or terminate a provider immediately. In all
cases, APS-PR will notify the provider in writing that these actions have or
are about to occur and inform them of the reasons for these actions, and
offer the provider the right to appeal the decision and review APS-PR
documentation.
F. PROVIDER APPEAL RIGHTS
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1. Appeals Process
To assure providers the right to appeal decisions made by APS-PR, an appeals policy
and procedure was implemented for situations in which a credentialing or recredentialing determination or a review of quality of care or service issues result in
alteration of provider privileges. The policy also indicates that as part of its responsibility
to safe- guard client members, APS-PR will notify the appropriate authorities when a
provider is terminated due to a serious quality deficiency.
Upon notification of the adverse determination, providers have 30 business days to
appeal. The appeal should be sent to the Provider Relations Manager at the address
provided below. Upon receipt, the appeal is date stamped and forwarded to the chair of
the Provider Appeals Sub Committee, who convenes the sub-committee. The subcommittee reviews the appeal, conducts an investigation of the data and renders a final
determination. The investigation includes a review of the substance of the appeal,
including all aspects of the clinical care involved when appropriate. The provider may be
asked to submit additional information or confirm data. In addition, queries to the
National Practitioner Data Bank, State Licensing Authority, Federation of State Medical
Boards (FSMB) and if appropriate, facilities where the practitioner has admitting
privileges may be made by the Provider Appeals Sub-committee.
SEND APPEALS TO:
APS HEALTHCARE PUERTO RICO, INC.
PROVIDER RELATIONS DEPT.
P.O. Box 71474
San Juan, PR 00936-8574
The final determination, made within twenty days of the appeal, may be to uphold,
modify or reverse the original determination. In any case, provider notification by the
Provider Appeals Sub Committee must be made within five business days of the final
determination. If circumstances beyond the committee’s control occur, the Provider
Appeals Sub Committee may be given an additional ten days to provide the
determination. The provider notification letter contains the final determination and the
reasons behind any delay.
The Provider Appeals Sub Committee maintains a provider appeals log to track and
trend the data and information. This aggregated data and information is submitted to
the Network Committee on a quarterly basis for review and incorporation into the
network quality improvement report submitted to the APS-PR Quality Improvement
Committee.
2. Reporting of Termination Decisions
In accordance with Federal Law, the National Practitioner Data Bank and the State
Licensing Agency shall be informed of APS-PR’s decision to terminate a provider:
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APS-PR will report to the National Practitioner Data Bank and the appropriate licensing
agencies all providers who have been suspended or terminated for quality of care
issues.
The provider is apprised during the sanctioning process that a report may be sent to the
licensing agencies and boards. The provider will then be afforded the opportunity to
further clarify issues and provide additional relevant information. In all cases, providers
will be given the right to appeal any credentialing or re-credentialing decision to the
APS-PR Provider Appeals Subcommittee.
G. PROVIDER EDUCATION
1. Provider Orientation Program
When new business is implemented in a market, APS-PR sponsors a Provider
Orientation Program for all network providers and appropriate administrative staff. The
purpose of this program is to orient new providers to APS-PR’s clinical philosophy,
operational policies and administrative procedures. The APS-PR Provider Manual is
reviewed and providers are briefed on APS-PR’s relationships with local clients. The
Provider Orientation Program is APS-PR’s first step in the development of long lasting
partnerships with providers. The Provider Orientation Program allows for the solicitation
of valuable input and feedback from network providers.
2. Provider Relations Department
APS-PR maintains a team to answer provider questions through an 800 number. The
phone lines are open from 8:30 a.m.- 5:30 p.m. Monday - Friday. The phone # is 1-800503-7929 extension 2742. Also, providers can be attended in person at APS Central
Office by previous appointment.
3. Change of Address or Tax Identification Number
Any change of a provider’s name, address, phone number, facsimile number, or tax
identification number is to be submitted in writing to the attention of the Provider
Relations Department. The request should be signed and dated by the provider and will
be accepted by mail or facsimile. To ensure timely claims processing, APS-PR is to be
notified as soon as a change occurs. If a requested change requires re-contracting or
amending a provider’s current agreement, the agreement or amendment must be
executed before the change becomes effective. For example, if a provider resigns from
one APS-PR practice group and then joins another, both APS-PR practice group
agreements will be amended. If a provider resigns from an APS-PR practice group to
establish an independent practice, the provider will no longer be considered active
unless accepted into the network as an independent practitioner.
4. Provider Satisfaction Survey
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In our effort to continually improve our business practices and our relationships with
providers, APS-PR PR will survey network providers annually to determine their level of
satisfaction with APS-PR . Providers are contractually obligated to participate in these
surveys as well as any other Quality Improvement Activities. The APS-PR Quality
Improvement Committee will distribute the results of these surveys in the aggregate to
each of APS-PR’s customers as well as to the network providers, via the Provider
Newsletter. Corrective actions may be taken by APS-PR to address problems that have
surfaced through the surveys in order to enhance the relationship between providers
and APS-PR.
5. Provider Newsletter
Every quarter, APS-PR distributes a Provider Network Newsletter to all network
providers. The newsletters update providers on APS-PR’s products and operational
procedures. It also provides a forum for sharing information about managed behavioral
health care conferences and resources.
H. ON SITE EVALUATION PROCESS
In accordance with the APS-PR Provider standards and the guidelines set forth by
NCQA, an On Site Evaluation will be completed with selected hospitals, programs,
individual practitioners and practice groups. As part of the credentialing process, an on
site evaluation may be conducted for these providers prior to acceptance to the
network, every three years Thereafter as part of the re-credentialing process, or earlier
if quality concerns are identified by the Credentialing Committee.
A Provider Operations staff member will meet with the provider to discuss the role of the
provider and of APS-PR in the provision of behavioral healthcare services to our
members. APS-PR policies and procedures will be reviewed and the provider’s
adherence to APS-PR standards will be evaluated.
The evaluation will consist of a review of the provider accessibility to APS-PR members,
the provider’s medical record keeping standards, and the provider’s office site
appearance. Records must be kept in locked files maintained in an area that protects
the confidentiality of the patient, and are not accessible to the general public. At the
conclusion of the evaluation, the provider will be informed of any deficiencies and given
the opportunity to submit a corrective action plan to redress those areas. The corrective
action plan must be submitted to the Credentialing Committee in writing within thirty (30)
days of the site visit.
I. TREATMENT RECORD REVIEW
1. In addition to On Site Evaluations, APS-PR may also conduct reviews of Provider’s
treatment records in accordance with Law 408 , HIPPA and national standards such as
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NCQA and AMA The providers included in the annual treatment record review sample is
based upon the volume of work done for APS-PR.
Treatment records may be reviewed on site in the providers office or APS-PR may
request that the records be copied and forwarded by mail to APS-PR for review. In any
case, the records should be blinded as the identity of the member and will be treated
confidentially by APS-PR. Please see below for the Treatment Record documentation
standards that are congruent to those of NCQA.
J. TREATMENT DOCUMENTATION GUIDELINES
1. Each page in the record contains the patient’s name or identification
number.
2. Each record includes the patient’s address, employer or school, home and
work telephone numbers including emergency contacts, marital or legal
status, appropriate consent forms (including consent for treatment) and
guardianship information if relevant.
3. All entries in the treatment record include the responsible clinician’s name,
professional degree, and relevant identification number if applicable.
4. All entries are dated.
5. The record is legible to someone other than the writer and in ink.
6. Relevant medical conditions are listed, prominently identified, and revised.
7. Presenting problems, along with relevant psychological and social
conditions affecting the patient’s medical and psychiatric status are
documented.
8. Assessment of severity and imminence of potential harm to self or others
is completed and documented at least once and then as often as
appropriate.1
9. Special status situations, such as imminent risk of harm, suicidal ideation,
or elopement potential, are prominently noted, documented, and revised in
compliance with written protocols.
10. Each record indicates what medications have been prescribed, the
dosages of each, and the dates of initial prescription or refills.
11. Allergies and adverse reactions are clearly documented.
1
CRITICAL INDICATOR
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12. A medical and psychiatric history is documented (for example: including
previous treatment dates, provider identification, therapeutic interventions
and responses, sources of clinical data, relevant family information, results
of laboratory tests, and consultation reports).
13. For children and adolescents, prenatal and prenatal events, along with a
complete developmental history (physical, psychological, social,
intellectual, and academic) are documented.
14. For patients 12 and older, documentation includes past and present use of
cigarettes, alcohol, illicit drugs, and prescription medication(s).
15. A mental status evaluation documents the patient’s affect, speech, mood,
thought content, judgment, insight, attention or concentration, memory,
and impulse control.
16. A DSM-IV diagnosis is documented, consistent with the presenting
problems, history, mental status examination, and/or other assessments.
17. Treatment plans are consistent with diagnoses and have both objective
measurable goals and estimated timeframes for goal attainment or
problem resolution.
18. The focus of treatment interventions is consistent with the treatment plan
goals and objectives.
19. Informed consent for medication and the patient’s understanding of the
treatment plan is documented. (For MDs/DOs only)
20. Patients who become homicidal, suicidal, or unable to conduct activities of
daily living are promptly referred to the appropriate level of care.
21. The treatment record documents preventive services, as appropriate (e.g.,
relapse prevention, stress management, wellness programs, lifestyle
changes, and referrals to community resources).
22. 2 Treatment record provides evidence of practitioner attempting to obtain
consent to communicate with other behavioral healthcare providers or
practitioners when appropriate.
23.
2
3
3
Treatment record provides evidence of communication and coordination
of care with other behavioral healthcare providers or practitioners if they
exist.
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24. 4 Treatment record provides evidence of practitioner attempting to obtain
consent to communicate with primary care physician (PCP) or other
ancillary providers/health care institutions when appropriate.
25. 5Treatment record provides evidence of coordination of care with primary
care provider (PCP) or other ancillary providers/health care institutions
when they exist.
26. The treatment record documents dates of follow-up appointments or, as
appropriate, a discharge plan.
APS-PR reviews a random sample of treatment records. Records are selected from
APS-PR enrollees that have started treatment with the practitioner during the prior year.
To ensure the confidentiality of patient information, APS-PR reviewers or vendors use
the following procedures:
•
•
•
•
Reviewers are licensed healthcare professionals with a contractual and
professional obligation to maintain confidentiality;
The provider is given advanced notice of the review.
The provider is requested to blind all patient-identifying information, and
The records remain at the provider’s office throughout on-site review.
Three (3) treatment records are reviewed at each individual practitioner site. At
ambulatory organizational provider sites at least 10 records are reviewed, selected
across all practitioners at the site. Providers receive written notification of their results
within 90 days of the review. They receive their completed tool along with the record
keeping toolkit. Compliance with the standards requires an overall score of 60%.
Compliance with Critical Indicator #15, assess of severity and imminence of self harm
and requires a score of 80%. Compliance with Critical Indicators 34, 35, 36 and 37
requires a score of 60%. Providers who fall below the acceptable threshold (above) are
referred to the Provider Quality Monitoring Committee for further review and follow-up.
Results of the provider treatment record keeping review are documented in the provider
file and reviewed at the time of re-credentialing.
[ III ] UTILIZATION MANAGEMENT
APS-PR was founded upon the belief that quality and successful outcomes in
behavioral healthcare are achieved by providing access to the most appropriate care, at
the right time and in the least restrictive setting. In order to accomplish this ambitious
goal, APS-PR maintains an experienced staff of licensed clinicians on-site Monday
through Friday from 8 a.m. to 6 p.m., with availability 24 hours a day, seven days a
week. These clinicians bring to APS-PR significant mental health and substance abuse
(MH/SA) inpatient and outpatient experience gained in the field, together with a
4
5
CRITICAL INDICATOR
CRITICAL INDICATOR
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successful history of managing the utilization of behavioral healthcare services for our 8
million members.
The APS-PR Utilization Management (UM) process begins with a comprehensive
clinical intake including risk assessment. Fulfilling more than the traditional role of
determining medical necessity, we design our systems to serve as a resource to
patients, families and providers. Further, our clinical staff is always looking for
opportunities to develop and implement alternatives to the more typical adversarial
utilization review. For example, outpatient providers have the convenient option of using
the APS-PR automated Outpatient Treatment Review (OTR) form to submit clinical
information and obtain authorization for routine cases via fax. This process can be
completed without having to speak to a care manager.
The APS-PR Clinical Triage Tool system provides active, next day follow-up for all
members who have been identified through triage as “Urgent” or “Emergent”. Using our
Utilization Management Guidelines, written medical necessity criteria consistent with
national practice standards, our care managers work pro-actively with both the patient
and the provider to build consensus around the appropriate level of care, treatment plan
and goal. A copy of the most current APS-PR Utilization Management Guidelines is
included in this manual.
Utilizing a full continuum of care consisting of network providers who have been
credentialed to National Committee for Quality Assurance (NCQA) standards, our care
managers monitor the quality of care and provide ongoing clinical review of a member’s
treatment in collaboration with our provider partners throughout the entire process. In
addition, care managers maintain linkage with the PCP in order to ensure effective
coordination of care. In those instances where care managers and providers have
difficulty determining the proper diagnosis, course of treatment or proper level of care,
our physician advisors are available to offer assistance.
Another critical tool that aids APS-PR care managers in tracking and coordinating
ongoing care is our award-winning information system. The APS-PR clinical staff uses
this system to verify and track eligibility and benefits, document complaints about APSPR clinical or service issues, authorize services, document the electronic medical
record, generate certifications, initiate provider searches and document appeals. This
system also assists in tracking communications with primary care physicians and other
service agencies.
A. CLINICAL PROCEDURES
The procedures described in this section apply only when a provider is treating a
member who has a behavioral health care benefit plan that is managed by APS
Healthcare Puerto Rico, Inc.
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1. Referral and Authorization Procedures
APS-PR maintains a twenty-four (24) hours, toll free telephone through which members,
their families, primary care physicians and providers may request referrals for
behavioral health care services. Members are not required to obtain a referral from a
PCP to access behavioral health services, though APS-PR will work with a PCP to
obtain a referral should the occasion present itself.
2. Initial/Concurrent Review
An APS-PR Member Referral Coordinator processes member requests for routine
referrals during business hours. An APS-PR Member Referral Coordinator verifies
eligibility, updates demographic information, and educates members regarding their
benefits. In most instances, these call are received from the member actually seeking
treatment. However, APS-PR will work with a PCPs or family members with the
permission of the member seeking treatment.
The Member Referral Coordinator conducts a very brief, objective screening to ensure
that the member’s situation is non-urgent. (Any suspected urgent situation is
transferred to a Care Manager to handle the call.) Once this is established, the Member
Referral Coordinator searches the network for a provider who offers services that best
match the member’s clinical needs. The member is given the name and telephone
number of a geographically accessible network provider. The member is then
instructed to contact the provider to schedule an appointment. If a member is referred
to a practice group, APS remind the member to ask for an APS-PR credentialed
provider within the group at the time the appointment is made.
The APS-PR Member Referral Coordinator enters an authorization number into the
APS-PR data system, linking the provider with the member. The authorization number,
co-payment or coinsurance requirements are mailed to the provider once a week. For
those providers who do not have fax numbers, the authorization notice is mailed to the
provider.
Authorization for additional treatment sessions is based upon medical necessity and the
availability of benefits. To request authorization for additional sessions either complete
and fax the APS-PR Outpatient Treatment Review Form or call the APS-PR Care
Management Department to conduct a clinical review at least one week prior to the
last authorized session or send by fax or by mail an APS-PR Treatment Plan Form.
This review will include, but is not limited to, the following information: presenting
problem, DSM-IV diagnosis (all 5 axes), current symptoms, prior psychiatric and
substance abuse history and treatment, mental status, medications (dosage and side
effects), medical complications and significant medical history, treatment plan and
progress. The Care Manager’s decision to authorize further sessions will be based on
medical necessity. When treatment has been terminated with a member, the provider is
to inform APS-PR. At that time, any unused authorized sessions will be credited to the
member’s benefit.
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3. Medication Management
When a member who is receiving ongoing outpatient psychotherapy requires a referral
to a psychiatrist for a medication evaluation or for ongoing medication management, the
primary therapist is to contact APS-PR to obtain a referral for that member. When in
agreement with the provider’s recommendation, the APS-PR Care Manager will
authorize a psychiatric evaluation. Upon review of the evaluation with the psychiatrist,
the Care Manager will authorize medication management visits. When a member is in
treatment with both a therapist and a psychiatrist, both providers are expected to work
together in the coordination of that member’s care. Ongoing authorization for
medication management can be obtained by either faxing the required clinical
information on APS-PR’ medication management form, or by contacting an APS-PR
care manager for a telephone interview.
4. High Risk Indicators
APS-PR Care Managers closely monitor all members identified as at risk due to the
following conditions, characteristics or past treatment histories:
Criteria for the admission to the Program of High Risk
1. Re-admission within 30 days after the discharge
2. Two or more suicide/homicide attempts within 30 days
3. Homicide attempt
4. Admission of children less than 12 years of age
5. Admission of children less than 12 years of age with psychotic episode.
6. Specific cases identified by the Health Plan, the Consultant of Medical Affairs, APSPR-PR Clinical Practitioners, or Clinic Administrators
Should you identify a member with a high-risk indicator, contact APS-PR’s Care
Management Department.
5. Hospital and Program Services
When a member demonstrates a need for admission to an inpatient facility, a partial
hospitalization program, an intensive outpatient program or an evaluation for these or
any other services, a call to APS-PR must be made to request authorization for services
or to schedule an evaluation to determine the most appropriate level of care. All
hospital and program admissions must be pre-authorized unless there is a lifethreatening medical emergency (see Emergency Services).
The Care Manager will schedule an evaluation or admission based on the information
provided by the caller. The Care Manager, in conjunction with the hospital or program’s
attending physician or designee, will review the clinical information to determine the
type and intensity of treatment that would most benefit the member. The decision to
authorize an admission to a hospital or a program will be based on medical necessity.
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When a Care Manager authorizes an admission, a preliminary treatment plan is
formulated and the authorized length of stay or number of sessions is communicated to
the hospital or program. When additional sessions or days are required, the attending
physician or designee is to call APS-PR to discuss further treatment prior to the last day
of authorized services.
6. Emergency Services
In accepting a referral from APS-PR, network providers accept the responsibility of
providing twenty-four (24) hour urgent and emergency services for our members.
Patients in active treatment should be given instructions on how to contact their provider
or a covering provider in the case of an emergency.
Members who have behavioral health care benefits that are managed by APS-PR are
instructed to go to an emergency room only when the member, acting reasonably,
believes that an emergency condition exists. As stated previously, it is expected that
answering machine messages and/or answering services provide patients with a
number to contact the provider in an emergency. A message that states that the patient
should go to the emergency room is not acceptable.
In the member’s Group Membership Agreement, a “medical emergency” is defined as
the sudden onset of a medical condition manifesting itself by acute symptoms of
sufficient severity such that the absence of immediate medical attention could
reasonably result in:
permanently placing the members health in jeopardy;
severe impairment to bodily function;
serious and permanent dysfunction to any body organ or part.
Emergency services are delivered by a provider in cases where the provider has
conducted a clinical diagnostic interview sufficient to determine that the member is
harmful to self or others and in need of immediate intervention to foster member safety.
Intervention may include safe transport if medical necessity applies, and any of the
following: inpatient evaluation, a 23-hour observation bed, inpatient admission, or
inpatient detoxification. The member is the clinical responsibility of the provider who
arranges transportation and provides clinical support while continuously monitoring the
member to prevent harm. Intervention should be immediate and constant until the
clinical situation is de-escalated.
Once an intervention is completed, the provider is requested to call the care manager
within six (6) hours to report the outcome and review the next level of care requirements
for precertification. If a colleague or office staff member is available, contacting the care
manager immediately for authorization and assistance is recommended.
The member’s behavioral health care provider is expected to triage all other urgent and
emergency situations. APS-PR Care Managers are available through our 800 number
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twenty-four (24) hours per day to assist providers with emergency cases. Contact a
Care Manager whenever a member requires emergency attention.
APS Healthcare Puerto Rico, Inc. must be notified by the hospital, admitting physician
and/or patient of an emergency admission within two (2) hours of the admission. Once
notified, procedures for assigning an authorized length of stay are the same as for
elective admissions.
When a provider is contacted by a patient in need of an outpatient emergency
intervention, the provider is to call APS-PR to obtain authorization. If the member
requires a service that the provider cannot offer, the provider is to contact the Care
Management Department to arrange for the required intervention.
7. Discharge Planning
Discharge planning begins at the initiation of all hospital and program services. It
includes preparing the patient and the family for the next level of care and arranging for
placement or provision of additional services. APS-PR Care Managers will work with
hospitals and programs to assure a smooth transition and the use of participating
providers for follow-up care within 5 days of discharge.
8. Electroconvulsive Therapy (ECT)
APS-PR follows guidelines consistent with national standards on electroconvulsive
therapy (ECT) as promulgated by the American Psychiatric Association’s task force on
electroconvulsive therapy.
When covered under a member’s Group Medical
Agreement, outpatient and inpatient electroconvulsive therapy may be authorized by an
APS-PR Physician Advisor. Inpatient and outpatient ECT must be conducted at a
network facility by a network psychiatrist who is an ECT sub-specialist. Inpatient ECT
must be conducted during an authorized inpatient stay. An APS-PR Physician Advisor
will authorize a specific number of inpatient or outpatient ECT sessions based on
medical necessity.
9. Psychological Testing
As behavioral health care shifts its focus to target specific clinical outcomes, the role of
psychological testing becomes more refined and discrete. Psychological testing is to be
used as an adjunct to assist clinicians with complex differential diagnoses. All
psychological testing, inpatient and outpatient, requires pre-authorization from a APSPR Care Manager.
10. Neuropsychological Testing
The task of neuropsychological testing is to understand the behavioral, cognitive or
emotional difficulties of adults and children brought forth by cerebral dysfunction.
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Neuropsychological testing is used predominantly for medical-surgical or comorbid
conditions.
APS-PR will consider authorizing neuropsychological testing for psychiatric conditions
only after a neurological assessment and a psychiatric assessment have been
conducted. Approval of neuropsychological testing will be based on the necessity to
refine or differentiate a psychiatric diagnosis resulting in a modification and/or
enhancement of the treatment plan. An expert neuropsychology consultant or a
physician advisor who is board certified in neurology is used to make decisions in this
area. Requests for neurological testing when a definitive organic condition is present
will be referred to the members Health Plan or PCP.
11. Referrals to Other Providers
One of APS-PR’s highest priorities is to offer its members a fully integrated system of
care. We strive to develop networks of providers which offer a spectrum of behavioral
health care services and specialties available today. When a provider recognizes that a
member would benefit from additional behavioral health care services, such as group
therapy, a medication evaluation or an intensive outpatient program, the provider is to
contact the Care Management Department to request an authorization to another APSPR provider. Referrals for medical/surgical services are to be coordinated through the
member’s medical plan and/or Primary Care Physician.
12. Primary Care Liaison Program
APS-PR’ clinical philosophy places an emphasis on the integration on behavioral and
medical health care. The purpose of the Primary Care Liaison Program is to assure the
coordination and integration of care provided to HMO members by APS-PR network
providers and the members’ Primary Care Physician. APS-PR maintains that the
successful coordination and integration of the behavioral and medical health care
delivery system results in improved quality of care and outcomes as well as reduced
costs due to increased efficiency. In the last few years, an increase in awareness has
occurred in the medical community of the need for PCP contact with medical and
behavioral health specialists who treat their patients. Many psychiatric problems
present as medical conditions and many medical problems present with psychiatric
symptoms.
While APS-PR recognizes problems that exist in maintaining member confidentiality, we
also understand the benefit of an informed PCP as to a patient’s whole health care.
Such information is relevant when the provider patients:
•
•
•
•
Are taking prescription drugs or medications;
had a recent inpatient stay for mental health or substance abuse;
Have a substance abuse problem that affects their physical health; or
Represents a danger to themselves.
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APS-PR providers will provide the member’s PCP with the following information:
•
•
•
•
•
•
list of medication and changes in medication prescribed by the behavioral health
care provider (psychiatrist);
indications of side effects of medications and/or drug interactions;
suspected medical/physical conditions;
impatient hospitalization with or without physical comorbidity;
significant substance use;
potential effects on the member’s physical condition and/or medical care due to
proposed or active behavioral health care treatment;
In order to communicate with the member’s PCP, the provider will need to have the
member sign an Authorization for Release of Information. Providers should educate
their members about the benefits of their PCP being informed of the initiation and
progress of their behavioral health care. A Release of Information sample form is
included as an attachment of this manual.
B. CLINICAL PRACTICE GUIDELINES
NCQA requires that APS-PR adopt and disseminate practice guidelines that are
relevant to its membership. In order to meet the intent of these NCQA standards, APSPR endorses practice guidelines published by other professional organizations. APSPR providers are informed of the adoption of these guidelines and about how providers
may obtain copies via mailings. APS-PR provider practices are expected to conform to
the treatment protocols contained in adopted guidelines. Compliance with the practice
guidelines will be assessed via treatment record reviews conducted by APS-PR
annually.
C. INTRODUCCTION TO THE MEDICAL NECESSITY AND LEVELS OF CARE
DETERMINATION CRITERIA OF APS-PR
APS-PR believes that patients are best treated in the least restrictive environment
consistent with the patient’s symptoms, support and safety requirements. The goal of
treatment is the restoration of the patient to optimal functionality and independence.
This document is intended to be a starting point and common reference for clinical
discussion. As such, it focuses on the patient’s clinical history, presenting symptoms
and available resources in recommending a level of care. We recognize that resources
for the full continuum of care do not exist in all locations. In those cases, we will
recommend a higher level of care than medically necessary in order to assure safe and
effective treatment. “Medical Necessity” as the term is used here, means that care
which is determined to be effective, appropriate and necessary to treat a given patient’s
disorder.
Each level of care is indicated as either Psychiatric or Substance Dependence (except
for the outpatient level of care which subsumes both) and review for level of care
determination proceeds in a logical progression to confirm:
Rev. 12.2013
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•
•
•
•
The presence of a properly diagnosed mental health or substance abuse
disorder amenable to treatment;
Symptoms of sufficient severity to meet the required criteria for admission;
The illness by accepted medical standards is expected to improve significantly
through medically necessary and appropriate care as it relates to the level of
care requested; and
Clinical requirements for continuing care at that level.
Discharge criteria, program content, treatment interventions etc., are not included in an
attempt to avoid being too prescriptive and preempting clinical discourse. Therefore,
determinations for discharge from a given level of care are clear: when the patient no
longer appears to meet the required criteria for continuing care at a given level of acuity,
discharge to a lower level of care is recommended.
As an integral part of our quality improvement process, we will review annually and
revise this document as needed based upon developments in the professional literature
and feedback from all participants in treatment reviews. However, we welcome your
comments and suggestions at any time.
D. DEFINITIONS FOR LEVELS OF CARE
APS-PR recognizes the following as distinct levels of care:
Psychiatric Services:
1.
Acute Inpatient—The highest intensity of medical and nursing services provided
within a structured environment providing 24 hours skilled nursing and medical
care. Full and immediate access to ancillary medical care must be available for
those programs not housed within general medical centers.
2.
Residential Treatment— Care provided at a subacute level with skilled nursing
care. These may be intermediate care facilities (ICF) or have other licensing
designations that may vary by state.
3.
Partial Hospital— an intensive, non-residential, level of service where
multidisciplinary, medical and nursing services are required. This care is
provided in a structured setting, similar to inpatient intensity, meeting for more
than four hours (and, generally, less than eight hours) daily.
4.
Intensive Outpatient—Multidisciplinary, structured services provided at a
greater frequency and intensity than routine outpatient treatment. These are
generally up to four hours per day, up to five days per week. Common treatment
modalities include individual, family, group and medication therapies.
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5.
Outpatient—The least intensive level of service. Typically provided in an office
setting from 60 to 90 minutes (for group therapies) per day.
6.
23-Hour Observation—“23-hour beds” are defined as a period of up to 23 hours
during which services are provided at less than an acute level of care. It is
indicated for those situations where full criteria are not met because of external
factors relative to information gathering or risk assessment yet the patient clearly
at risk for harm to self or others.
Substance Abuse Services:
1.
Inpatient Detoxification—Detoxification services provided in a 24 hours hospital
setting with full nursing and medical care. Generally provided on inpatient
psychiatric units, services can also be given on a medical/surgical unit when
needed for safety or in the absence of adequate services elsewhere.
2.
Inpatient Rehabilitation—Twenty-four hour per day supervised care for a
substance dependence diagnosis not requiring full nursing and medical services.
3.
Residential Treatment—Care provided at a sub-acute level with skilled nursing
care. These may be intermediate care facilities (ICF) or have other licensing
designations that may vary by state.
4.
Outpatient/Ambulatory Detoxification—Detoxification services delivered within
a structured program having medical and nursing supervision where
physiological consequences of withdrawal have not life-threatening potential.
5.
Partial Hospital—An intensive, non-residential, level of care where
multidisciplinary, medical and nursing services are required. This care is
provided in a structured setting, similar in intensity to inpatient, meeting for more
than four hours (and, generally, less than eight hours) daily. Such care is
appropriate for substance abuse treatment when provided in conjunction with
ambulatory detoxification or when medical comorbidity or other complications
make less intensive levels of care unsafe or inadequate.
6.
Intensive Outpatient Programs—Multidisciplinary, structured services provided
at a frequency of up to four hours daily, up to five days per week for the
treatment of a substance dependence disorder.
7.
Outpatient—For substance dependence disorders, this is not a recommended
level of care. However, exceptions may exist for which this will be a necessary
level of care (see: Level of Care Determination Criteria).
E. 23-Hour Observation
(ALL TYPES OF CARE, ALL AGE GROUPS)
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(Note: “23-hour beds” are defined as a period of up to 23 hours during which services
are provided at less than an acute level of care. It is indicated for those situations
where full criteria are not met because of external factors relative to information
gathering or risk assessment yet the patient clearly at risk for harm to self or others.)
A. Medical Necessity—(All must be met to consider for treatment.)
1. The patient must have been assessed, to a reasonable degree of medical certainty,
as having a psychiatric illness or substance abuse disorder by a licensed health
professional.
2. Symptoms of this illness must accord with those described in the Diagnostic and
Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria—(Either 1 or 2 and 3 are sufficient to recommend treatment.)
1. The presenting clinical problem likely represents a transient disruption of the
patient’s clinical baseline which will likely remit with a period of structure and
observation.
or
2. The patient presents with a significant history of sedative/hypnotic dependence
representing a genuine risk of rapidly developing signs and symptoms of withdrawal,
which will meet inpatient detoxification criteria
and
3. The presenting clinical problem represents a clear, proximal risk of harm to self or
others.
F. Inpatient (Acute Care)
PSYCHIATRIC: (ADULT, CHILD, ADOLESCENT*)
A. Medical Necessity—(All are required to consider for admission.)
1. The patient must have been diagnosed with a psychiatric illness by a licensed
mental health professional.
2. Symptoms of this illness must accord with those described in the Diagnostic and
Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria - (At least one criterion needs to be met to recommend
admission).
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1.
2.
3.
4.
Patient presents suicidal ideation and intention, which represent significant
or imminent risk of self harm, that 24 hours hospitalization and observation
are necessary for the patient’s safety.
Patient presents with a recent history of grossly disrupted and/or violent
behavior representing clear and present danger of serious harm to others.
The patient’s psychiatric condition impairs his/her basic functional capacity
as to represent a genuine and proximal risk of danger to self such that 24hour intensive nursing and medical treatment are required.
Diagnosis and/or treatment is/are clearly unsafe or impossible to provide
in an outpatient setting and can only be accomplished with 24 hours
intensive nursing and medical care.
C. Continuing Care Criteria - (At least one criterion needs to be met to recommend
admission).
1.
2.
3.
Daily physician and staff progress notes clearly describe the patient’s lack
of progress despite adequate clinical intervention and/or the emergence of
new symptoms sufficient to meet acute care criteria.
Daily physician progress notes indicate serious medical complications of
pharmacotherapy or other somatic treatments such that transition to a
lower level of care represents clear risk of harm.
Daily progress notes indicate that attempts to transition to a lower level of
care have resulted in a reemergence of symptoms sufficient to meet acute
care criteria.
* Additional Child/Adolescent Criterion—(Must be met for continuing care.)
Documented evidence of significant family involvement at least three times weekly or
clearly documented evidence that such is medically contraindicated.
G. Inpatient Detoxification
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT*)
A. Medical Necessity—(All are required to consider for admission.)
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed mental health professional or equivalent licensed
substance abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria—(All three required for admission.)
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1. The patient has a documented history of severe, continuous dependence on
alcohol and/or sedative/hypnotic drugs and withdrawal from the substance of
abuse represents a genuine potential for serious physical harm.
2. Detoxification services are either not available on an outpatient basis or
require 24 hours intensive nursing and medical treatment on an inpatient
basis for medical reasons of safety.
3. The patient currently exhibits severe signs and symptoms of active withdrawal
and/or has a history of medically documented withdrawal seizures or delirium
tremens.
C. Continuing Care Criteria—(Both criteria must be met to recommend continuing
care.)
1. Daily physician documentation of physical signs and symptoms of active
withdrawal which require 24 hours intensive nursing and medical care.
2. Clear, documented clinical evidence of the need for skilled nursing and
medical treatment for active withdrawal.
* Additional Adolescent Criterion—(Must be met to recommend continuing care.)
Documented evidence of family involvement in both family therapy as well as family
education and support or clearly documented evidence that such is medically
contraindicated.
H. Inpatient Rehabilitation
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT*)
A. Medical Necessity—(All are required to consider for admission.)
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed mental health professional or equivalent licensed
substance abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria—(All criteria must be met to recommend admission.)
1. Documentation of a history of severe and continuous alcohol and/or
substance dependence.
2. The patient’s psychosocial support system is so impaired as to preclude
effective outpatient therapy (e.g. family are active abusers) or outpatient
therapy is clearly unsafe at this time because direct physical harm will be an
immediate consequence of a return to substance abuse (e.g. pancreatitis,
endocarditis).
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C. Continuing Care Criteria—(All criteria must be met to recommend continuing
care.)
1. Daily physician progress notes indicate continuing clinical problems (other
than placement issues) or the emergence of new clinical problems that are
severe enough to meet admission criteria.
2. Family involvement in treatment and discharge planning at least three times
weekly and introduction to family supports (e.g., Al-Anon, Nar-Anon) or clear
documentation that such is medically contraindicated or inappropriate.
3. A lower level of care is either clearly unsafe or physically unavailable.
4. Documentation of patient participation in abstinence-based groups (e.g. NA,
AA) and discharge planning which includes attendance in these or similar
community-based supports.
* Additional Adolescent Criterion—(Must be met to recommend continued care.)
Documented evidence of family involvement in both family therapy as well as family
education and support or clearly documented evidence that such is medically
contraindicated.
I. Partial Hospitalization
PSYCHIATRIC CARE: (ADULT, CHILD/ADOLESCENT*)
(Note: Partial Hospitalization is a level of care tantamount to the acute level of care
with the singular exception that the patient does not require 24 hours medical and
nursing care. It is intended to be provided up to eight hours per day, up to seven times
per week.)
Medical Necessity—(All are required to consider for admission.)
A.
1. The patient must have been diagnosed with a psychiatric disorder by a
licensed mental health professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
Admission Criteria—(All criteria must be met to recommend admission.)
B.
1. The patient’s mental condition requires skilled medical and nursing
observation (e.g. serial mental status checks, medication administration,
monitor vital signs) and is likely to improve with this intervention.
2. Clinical documentation clearly indicates that the patient could not be treated
safely at a lower level of care or that partial hospitalization could safely
substitute for acute inpatient care.
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3. The patient’s psychosocial supports are such that the patient can be
supervised and maintained without clinical supervision for that period of time
outside the program.
4. The patient’s condition requires multidisciplinary intervention for four (or
more) hours daily and more than three days per week.
C.
Continuing Care Criteria—(All criteria must be met to recommend
continuing care.)
1. Despite adequate treatment, the patient continues to exhibit signs and
symptoms that led to the admission, or new problems have emerged which
themselves meet the criteria for PHP admission.
2. The patient’s problems must be clearly documented in the medical record and
there must be a progress note by the provider for each day of treatment.
3. There must be clear clinical documentation that transition of the patient to a
lower level of care would result in exacerbation or re-emergence of symptoms
sufficient to meet PHP admission criteria.
* Additional Child/Adolescent Criterion—(Must be met to recommend continuing
care)
There is documented evidence of significant family involvement at least twice weekly
or clear documentation that such is medically contraindicated.
J. Partial Hospitalization
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT*)
(Note: Partial Hospitalization (PHP) is a level of care tantamount to the acute level of
care with the singular exception that the patient does not require 24 hours medical and
nursing care. It is intended to be provided up to eight hours per day, up to seven times
per week.)
Medical Necessity—(All are required to consider for admission.)
A.
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed mental health professional or equivalent licensed
substance abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
Admission Criteria—(All criteria must be met to recommend admission.)
B.
1. Clinical documentation of a need for multidisciplinary, highly structured,
coordinated treatment of a substance-related disorder which clearly indicates
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that the patient could not be treated safely at a lower level of care or that
partial hospitalization can safely substitute for acute inpatient care.
2. The patient’s psychosocial supports are such that the patient can be
supervised and maintained without clinical supervision for that period of time
outside the program.
3. The patient’s condition requires intensive medical and nursing care more than
four hours daily and more than three days per week.
4. In cases with numerous treatment failures, evidence that the patient has
recently worked to complete a course of treatment but has not been able to
complete his/her treatment goals in that setting. Documentation must be
provided which confirms the therapeutic potential of this intervention to enable
recovery.
Continuing Care Criteria (All criteria must be met to recommend continuing
care.)
C.
1. Despite adequate treatment, the patient continues to exhibit signs and
symptoms that led to the admission, or new problems have emerged which
themselves meet the criteria for PHP admission.
2. The patient has established a recovery plan, which includes: APS-PR
triggers, sober support systems, meeting schedules, and commitment to
lifestyle changes to encourage recovery and prevent APS-PR.
3. The patient demonstrates consistent work on treatment goals, the ability to
self-report difficulties in the treatment progress, and has the ability to use
cognitive/behavioral interventions to alter behavior patterns.
* Additional Criterion for Adolescents—(Must be met to recommend continuing care)
Documented evidence of family involvement in both family therapy as well as
family education and support at least three times weekly or clearly documented
evidence that this is medically contraindicated.
K. Outpatient Detoxification (Ambulatory Detoxification)
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT*)
(Note: This level of care is intended for those patients who require detoxification prior
to starting rehabilitative therapy for chemical dependence but do not require inpatient
treatment for safety. It is appropriate for individuals who are not medically compromised
and who are unlikely to develop medically dangerous symptoms of withdrawal. Such
patients require intensive medical and nursing care but do not require 24 hours
observation and support.)
Medical Necessity—(All are required to consider for treatment)
A.
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed clinical professional or equivalent licensed substance
abuse professional.
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2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B.
Treatment Criteria—(All criteria must be met to recommend treatment)
1. The patient requires skilled medical and nursing care in order to accomplish
safe detoxification.
2. Clinical documentation clearly indicates that the patient could not be treated
safely at a lower level of care.
3. The patient’s psychosocial supports are such that the patient can be
supervised and maintained without clinical supervision for that period of time
outside direct supervision.
4. The patient’s condition is such that s/he is able to comprehend instructions
and access medical help if needed.
C.
Continuing Care Criteria—(All criteria must be met to recommend
continuing care.)
1. The patient continues to display signs and symptoms consistent with
withdrawal, which represent a proximal risk of harm if not treated.
2. These problems must be clearly documented in the medical record, and there
must be a progress note by a physician for each day the patient is present.
3. There must be documentation for each day of treatment that attempts to
transition the patient to a lower level of care would result in re-emergence of
symptoms sufficient to meet admission criteria.
4. Evidence of patient awareness that detox is an initial phase of treatment and
contracts for continuing treatment at a lower level of care.
• Additional Criterion for Adolescents: For adolescents, there must be clearly
documented evidence of parental (or equivalent guardianship) consent to and
understanding of treatment as well as documented assessment of capacity to
support and maintain the patient after hours.
L. Intensive Outpatient Therapy
PSYCHIATRIC CARE: (ADULT, CHILD/ADOLESCENT*)
This level of care includes services at lesser levels of acuity than partial hospitalization.
It is intended to be provided less than four hours daily but may be offered up to seven
days weekly.
A. Medical Necessity—(All are required to consider for treatment.)
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1. The patient must have been diagnosed with a psychiatric disorder by a
licensed mental health professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria—(All criteria must be met to recommend treatment.)
1. There is documentation of significant and acute deterioration in social,
occupational, educational or family functioning.
2. The proposed treatment plan addresses the signs and symptoms consistent
with the observed deterioration in functioning.
3. The patient’s condition will benefit from the proposed intervention.
4. There is at least moderate impairment (a GAF less than 70).
C. Continuing Care Criteria—(All criteria must be met to recommend continuing
care.)
1. The patient continues to exhibit signs and symptoms consistent with
admission criteria.
2. The treatment plan reflects ongoing interventions to alleviate these
impairments.
3. Clinical documentation supports that attempts to transition to a lower level of
care would likely result in exacerbation of the illness.
• Additional Criterion For Children/Adolescents: There is clear documented
evidence of significant family involvement with and adherence to treatment or clear
evidence that this is medically contraindicated.
M. Intensive Outpatient Therapy
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT*)
This level of care includes services at lesser levels of acuity than partial hospitalization.
It is intended to be provided less than four hours daily but may be offered up to seven
days weekly.
A. Medical Necessity— (All are required to consider for treatment.)
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed clinical professional or equivalent licensed substance
abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
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encounter between the professional and patient.
B. Admission Criteria—(All criteria must be met to recommend treatment.)
1. The patient has a history of recent and/or continuous substance
abuse/dependence which is meeting DSM-IV criteria but who is stable and
competent enough to be adequately treated at this level of intervention.
2. There is clinical evidence which shows that the support of 12-step groups (or
other self-help groups) plus regular outpatient care is inadequate to assure
abstinence and recovery.
3. In cases with numerous treatment failures, evidence that the patient has
recently worked to complete a course of treatment but has not been able to
complete his/her treatment goals in that setting. Documentation must be
provided which confirms the therapeutic potential of this intervention to enable
recovery.
C. Continuing Care Criteria—(All must be met to recommend continuing care.)
1. The patient continues to exhibit signs and symptoms consistent with
admission criteria.
2. The patient demonstrates consistent work on treatment goals, the ability to
self-report difficulties in the treatment progress, and has the ability to use
cognitive/behavioral interventions to alter behavior patterns.
3. The patient’s abstinence is monitored through random urine screens and
specific modifications to the treatment plan are made in response to positive
urines.
4. The treatment plan identifies individual problems in recovery, prioritizes them
and has a focused plan for resolution.
5. Documented evidence of family involvement in both family therapy as well as
family education and support or clearly documented evidence that this is
medically contraindicated.
N. Outpatient Care
PSYCHIATRIC/SUBSTANCE DEPENDENCE
This level of care is the least intensive level of treatment and represents the majority of care
delivered. It is intended from 15 minutes (medication management) up to 90 minutes (group
therapy) per day not more than twice weekly.
A. Medical Necessity - (All are required to consider for treatment.)
1. The patient must have been diagnosed with a psychiatric or Substance
dependence disorder by a licensed mental health professional or equivalent
licensed substance abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
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3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria—(All must be met to recommend treatment.)
1. As a consequence of a DSM-IV diagnosis, the individual is experiencing
significant impairment in functioning in one or more of the following areas:
•
social,
•
occupational,
•
educational or
•
family role.
2. The proposed treatment plan is focused on:
•
adaptive responses to present impairments,
•
clearly defined and measurable goals and
•
a defined time frame.
3. The patient has the requisite cognitive and emotional skills necessary to
benefit from the proposed treatment plan.
C. Continuing Care Criteria - (All must be met to recommend continuing care.)
1. There is evidence that the patient is working to complete treatment goals and
is attending sessions as scheduled.
2. The patient continues to exhibit impairment requiring further treatment (GAF
<70).
3. The treatment plan clearly addresses the impairments necessitating ongoing
care.
4. If the GAF is >70, the patient has a diagnosis of a persistent DSM-IV disorder
which requires maintenance treatment to avoid recurrence of symptoms.
O. Residential Treatment (RTC, Domiciliary Care)
PSYCHIATRIC CARE: (CHILD/ADOLESCENT)
(Note: Residential Treatment is defined as 24 hours, supervised, inpatient level of care
provided to children and adolescents who have long-term illnesses not likely to respond
to short-term interventions. They should provide, in addition to diagnostic and treatment
services, instruction and support toward attainment of basic living skills, which will
enable them to live in the community upon discharge.)
A. Medical Necessity - (All are required to consider for admission.)
1. The child or adolescent has been diagnosed with a psychiatric disorder by a
licensed mental health professional.
2. Symptoms of this illness accord with those described in the Diagnostic and
Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
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3. The diagnosis must have been arrived at prior to admission in a face-to-face
encounter between the professional and patient.
B. Admission Criteria - (All must be met to recommend admission.)
1. There is clear clinical evidence that the child/adolescent has a severe mental
illness, which requires a level of intensity of services not available in the
community.
2. The illness or disorder is likely to improve with active treatment.
3. Without this intervention, there is clear evidence that the child/adolescent will
likely decompensate and represent a proximal risk of serious harm to self or
others.
C. Continuing Care Criteria—(All must be met to recommend continuing care.)
1. The patient continues to exhibit signs and symptoms consistent with
admission criteria.
2. There is a complete, multidisciplinary, individualized treatment plan, which
includes input from the patient and family.
3. The treatment plan defines clear, measurable objectives leading to a goal of
return to the community.
4. There is documented evidence of active psychiatric care which is symptomfocused and specific to the child/adolescent’s diagnosis.
5. There is documented evidence of active family therapy at least weekly or
clearly documented evidence that such is either impossible or medically
contraindicated.
P. Residential Treatment (RTC, Domiciliary Care)
SUBSTANCE DEPENDENCE: (ADULT/ADOLESCENT)
(Note: Residential Treatment for substance dependence is defined as 24 hours,
supervised, inpatient level of care provided to adults and adolescents who have longterm substance use disorders not likely to respond to short-term interventions. They
should provide, in addition to diagnostic and treatment services, instruction and support
toward attainment of basic skills, which will enable them to maintain sobriety in the
community upon discharge.)
A. Medical Necessity - (All are required to consider for admission.)
1. The patient must have been diagnosed with a substance dependence
disorder by a licensed clinical professional or equivalent licensed substance
abuse professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must have been arrived at prior to admission in a face-to-face
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encounter between the professional and patient.
B. Admission Criteria—(All must be met to recommend admission.)
1. There is a clearly documented history of significant impairment in all realms of
life as a consequence of a substance abuse disorder.
2. Evidence that the patient has recently worked to complete a course of
treatment but has not been able to complete his/her treatment goals in a less
restrictive environment.
3. There is credible clinical evidence that, without 24 hours support and care,
the patient is likely to suffer serious harm or present a risk of same to others
as a direct consequence of the substance abuse disorder and/or related
behavioral disturbance.
4. The patient’s external support systems are inadequate to sustain treatment at
a lower level of care.
C. Continuing Care Criteria (All must be met to recommend continuing care.)
1. The patient continues to exhibit signs and symptoms consistent with
admission criteria.
2. There is documented evidence of active participation in and compliance with
treatment by the patient.
3. There is a complete, multidisciplinary, individualized treatment plan, which
includes input from the patient and family.
4. The treatment plan defines clear, measurable objectives leading to a goal of
return to the community.
5. There is documented evidence of active family therapy at least weekly or
clearly documented evidence that such is either impossible or medically
contraindicated.
6. There is evidence that return to the community at the time of review would
likely lead to relapse and represent a proximal risk of serious harm to self or
others as a direct consequence of the substance abuse disorder and/or
related behavioral disturbance.
Q. Methadone Maintenance
NoteThe purpose of methadone maintenance is the stabilization of an opiate
addiction. Multidisciplinary, structured services are provided at a frequency of up to two
hours daily, up to six days per week. Such care is appropriate for members meeting all
federal and state requirements for enrollment in this treatment modality at a licensed
facility. Treatment includes but is not restricted to administration of methadone, medical
supervision of dosage and dispensing, individual and group therapy.
A. Medical Necessity(All are required to consider for admission.)
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1. The patient must have been diagnosed with an active opiate addiction by a
licensed mental health professional or equivalent licensed substance abuse
professional. Symptoms of this addiction must accord with those described in
the Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSMIV).
2. The patient must meet all federal and state requirements for this treatment
modality. This includes documentation of prior failure at abstinence based
treatment modalities.
3. The diagnosis must have been arrived at prior to admission and in a face to
face encounter between the professional and the patient.
B. Admission Criteria(All criteria must be met to recommend admission.)
1. The patient has a history of prior failures at abstinence based treatment
modalities, recent and continuous opiate addiction which meets DSM-IV
criteria, but who is stable enough to utilize an outpatient treatment modality.
2. The patient has established a contract for behavioral changes while in
treatment that supports stabilization of his opiate addiction. These include
abstinence from other proscribed drugs and intoxicants, random urinalysis
and breathalyzer tests to verify abstinence, attendance at all required therapy
sessions, and agreement to conditions for involuntary detoxification if
stabilization in methadone maintenance is not demonstrated through progress
in completing treatment goals.
3. In cases with recent, prior treatment failures in this treatment modality,
documentation must be provided that confirms the therapeutic potential for
stabilization in this treatment intervention.
C. Continuing Care Criteria(All criteria must be met to recommend continuing
care.)
1. The patient continues to exhibit signs and symptoms consistent with
admission criteria.
2. The patient demonstrates consistent work on treatment goals, the ability to
self-report difficulties with treatment progress, and the use of
cognitive/behavioral interventions to alter behavior patterns.
3. The patient's abstinence is verified through random urinalysis and
breathalyzer tests. Specific modifications in the treatment plan are developed
in response to positive tests, and monitoring of these modifications
documents treatment progress or continued need for treatment modifications.
4. The treatment plan identifies specific, individual problems with stabilization. It
develops treatment strategies to resolve each problem and monitors the
patient's completion of the treatment strategies.
5. Prior to a transition to a lower level of treatment intensity, the treatment plan
identifies the conditions of stabilization that must be consistently
demonstrated to remain at the lower level of intensity. Conversely, there is a
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contract to return to a higher level of intensity if the conditions are not
consistently met.
6. Because of the continuing treatment goal of opiate stabilization the treatment
plan will identify all instances of substance substitution, cross addictions,
cross tolerance, triggers for using, and prevention actions for each identified
trigger.
7. Where non-compliance with the treatment plan or avoidance of developing
strategies for the treatment plan are demonstrated, the necessity for
involuntary detoxification must be discussed as a preliminary to noncertification of continued treatment.
R. Electroconvulsive Therapy (ECT)
(Note: A course of treatment is generally 6 to 12 ECT. If there is no discernible clinical
improvement after 6 to 10 treatments, indications for continued ECT should be formally
reassessed. The determination of inpatient or outpatient settings as the appropriate
level of care for administering ECT is determined separately based on the patient’s
clinical symptoms as they relate to our other levels of care criteria).
A. Medical Necessity(All are required to consider for treatment)
1. The patient must have been diagnosed with a psychiatric illness by a licensed
mental health professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV) and must be
amenable to ECT.
3. The diagnosis must be based upon a face-to-face evaluation between the
professional and patient
4. The psychiatrist who will perform the proposed ECT has completed a face to
face evaluation of the patient prior to his recommendation of the procedure.
B. ECT Criteria - (If the patient meets one of the 3 criterion, is sufficient for
recommendation for treatment)
1. When at least two courses of medication at maximum doses for adequate
length of time has been ineffective or the symptoms requires a rapid response
from one of the following diagnostic conditions:
•
•
•
Severe depression with significant risk of suicide
Severe mania
Catatonia
2. When the member has a history of a positive response to ECT and a lack of
response to medicine in the past
3. Comorbidity when the use of psychotropic medication is compromised by the
medical condition;
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S. Psychological Testing
APS-PR. believes that members recommended for outpatient testing are best treated
when the purpose of the testing, the extent of testing, the instruments used, and the use
of results and recommendations are understood by both parties. The goal of outpatient
testing is an increased understanding of the patient not readily available by other
means. This can include the patient's diagnosis, dynamics, therapeutic capabilities, or
treatment planning recommendations. Psychological testing has a wide variety of
instruments and techniques as well as post-test interpretation of the results that need to
be included in request evaluations.
Testing for purposes other than psychological/psychiatric treatment are excluded from
the benefit. Examples of this type of testing include occupational placement testing,
disability testing, educational testing, neurological testing and forensic testing.
Cases requesting neuro-psychological testing with possible indicators of organic
damage or history of head trauma, anoxia, heavy metal exposure or diagnosis
secondary to a medical condition will be coordinated with the medical plan under the
mixed medical protocol. Neurological testing that establishes an organic basis for the
changes in psychological functioning will continue to follow the protocol for mixed
medical management. Cases completing a neurological evaluation which rules out an
organic basis for symptoms will continue the evaluation process under the criterion.
A. Medical Necessity - (must meet All of the following criterion)
1. The patient must have been diagnosed with a psychiatric illness by a licensed
mental health professional.
2. Symptoms of this illness must accord with those described in the Diagnostic
and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
3. The diagnosis must be based upon a face-to-face evaluation between the
professional and patient.
4. The request for psychological testing must come from a Ph.D. psychologist or
psychiatrist who has completed a face to face evaluation of the member.
5. The request for neuropsychological testing must come from a neuropsychologist or psychiatrist who has completed a face to face evaluation of
the member. A neurologist may also request neuro-psychological testing.
B. Psychological Testing Criteria - (needs to meet criterion 1 and 2, 3, or 4)
1. The results of the testing needs, with reasonable medical certainty, to
potentially alter the treatment plan; and
2. Diagnosis and treatment approaches fluctuate, contradictory information is
evident and clinical direction requires an increased understanding of the
member; or
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3. The member's therapeutic response is significantly different from the
anticipated response and additional assessment and investigation has failed
to alter the therapeutic dynamics; or
4. Significant disruption in the member's performance of life skills which is not
accounted for by assessment, history, diagnosis, or ongoing observation.
T. ADVERSE DETERMINATIONAND APPEALS PROCESS
When appropriate APS-PR UM criteria is not met for the requested level of care, or
during a concurrent review, the physician advisor reviews the potential adverse
determination. Attending physicians/providers requesting the services may be contacted
by the physician advisor for additional information. If upon reviewing the additional
clinical information obtained, the Physician Advisor agrees that the requested level of
care does not meet APS-PR UM criteria, a non-certification will be completed. In all
cases, the provider is offered an alternative treatment option and provided the clinical
rationale for the adverse determination. Notification is provided by phone and in writing
to the provider or facility (if appropriate), and the member. The adverse determination
notifications include the principle reason(s) for the determination, instructions on how to
request an appeal of the determination and the alternative treatment option
recommended. In cases where the patient is in active treatment in any intensive level of
care, an expedited appeal completed within 72 hours of receiving all clinical information,
will be offered.
Further details on the appeal process will be given later.
U. REPORTING ADVERSE OCCURRANCES
Adverse occurrences are defined as suicides, attempted suicides, homicides, attempted
homicides, physical or sexual abuse. If a APS-PR member experiences such an
occurrence, the provider is to report the incident to APS-PR immediately. APS-PR will
supply the provider with a risk management protocol to assist the provider in an
intervention. Notification of APS-PR does not substitute for nor take precedence over
state or federally mandated reporting requirements for abuse, neglect or danger to self
or others.
APS HEALTHCARE PUERTO RICO, INC.
P.O. Box 71474
San Juan, PR 00936-8574
PHONE: (800) 503-7929 x. 3161
V. ANCILLARY SERVICES
APS-PR., HMO Plan customers maintain contracts with laboratory, radiology and other
specialty providers. When these services are used in conjunction with an HMO
member’s behavioral health care, the APS-PR provider is responsible for coordinating
those services with the member’s Primary Care Physician (PCP).
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1. Laboratory Services
Each of APS-PR Plan customers maintains contracts with laboratory providers. All lab
work must be done through these contracted providers. The provider ordering the lab
work will not be billed when using the participating laboratory. Use of any other
laboratory service will be the financial responsibility of the physician who orders the
test(s). APS-PR providers must use the APS-PR Plan’s contracted laboratory provider
for all outpatient lab tests. A listing of the HMO Plan’s contracted laboratory locations
can be found in the member’s Provider Directory. This information may also be
obtained by calling the local HMO Plan at the number listed on the member’s plan
identification card.
2. Radiology
For HMO members, all radiology services require a referral from the member’s Primary
Care Physician (PCP). Please contact the member’s PCP to coordinate these services.
CAT-Scan and MRI procedures also require prior authorization from the member’s PCP.
3. Pharmacy Services
HMO members with a prescription rider to their policy (indicated on their identification
care with an Rx), can fill prescriptions at any participating pharmacy. A complete listing
of participating pharmacies can be found in the member’s Provider Directory.
To learn whether a medication is a formulary medication for any individual plan, it is
necessary to contact the members HMO plan at the number on the back of the
member’s identification card. For questions related to your mental health medications
or prescription drugs, members should call the APS-PR’s Pharmacy Department.
W. MIXED PSYCHIATRIC/MEDICAL PROTOCOL
In order to promote the access and the delivery of quality care for members with both
medical-surgical and behavioral health conditions, APS-PR and the HMO customers
work together to successfully coordinate members’ care. Except in cases of medical
emergency, APS-PR or the HMO Plan contacts their counterpart prior to treatment
being rendered to coordinate the approval for the required or requested treatment.
Medical necessity, level of care criteria and administrative procedures are determined
by the payor responsible for claims adjudication. Pre-certification and concurrent review
requirements are determined by the benefit plan design. If questions arise concerning
the coordination of a member’s medical-surgical and behavioral health services, APSPR providers may contact APS-PR Care Management. Members utilizing outpatient
laboratory, pharmacy and other diagnostic service providers are to be referred to those
providers contracted by the HMO Plan. In such circumstances, the APS-PR provider is
responsible for coordinating these services with the member’s Primary Care Physician.
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[ IV ] CUSTOMER SERVICE
Customer Services Representatives are available Monday through Friday from 7:00
a.m. to 7:00 p.m. E.S.T. The primary function of the Customer Service Representatives
is assisting members to interact with APS-PR and participating physicians and
providers. Customer Service can be reached at (800) 503-7929 ext. 192710.
Specific functions of the Member Relations Department include, but are not limited to:
*
*
*
*
Verifying Customer Eligibility and Benefits for Specialists, Hospitals, and Ancillary
Providers.
Resolving Customer Complaints and Appeals..
Explaining APS-PR Policy, Procedures, and Benefits to Customers.
Enhancing Customer utilization of health plan services.
A. TERMINATED MEMBERS
Authorizations from APS-PR are not a guarantee of payment. APS-PR authorizes
services based on benefit eligibility information available at the time the authorization
decision is granted. If the member’s benefits are terminated between the time an
authorization is granted and the date of service, APS-PR will not reimburse the provider
for services provided (Unless specifically prohibited by law). In this situation, a provider
may bill the member directly for the services delivered at their usual and customary fee.
If APS-PR determines that a provider has been paid for services delivered to an
ineligible member, APS-PR reserves the right to collect the amount of the overpayment
from the provider or to withhold the overpaid amount from future payments.
In instances when a members benefits are terminated or benefits end for any reason,
providers are expected to work with APS-PR and the member to transition the member
to other care that is appropriate.
1. APS-PR is prohibited from retaliating against a Group or any Member, including
refusing to renew or canceling coverage under the existing agreement, because
Group or Member, or a person acting on behalf of Group or Member, reasonably
filed a complaint against APS-PR or appealed a decision of APS-PR relating to
the Member, including, but not limited to, a medical necessity determination.
APS-PR also is prohibited from retaliating against a Participating Provider for
reasonably filing a complaint against APS-PR or appealing a decision of APS-PR
for issues pertaining to themselves or on behalf of a Group or Member.
B. GRIEVANCE SYSTEM
All contracted providers should provide services of optimal quality at all times. APSPR Healthcare registers and responds to verbal and written complaints and
grievances received from beneficiaries or its authorized representative.
All
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comments are important and are viewed as a potential opportunity for
improvement in the care provided by contracted providers.
APS-PR has a grievance system in place to address enrollees concerns and
appeals of service decisions for all Lines of business.
Appeal process for members with Puerto Rico Government Health Insurance
The Grievance System includes Complaints, Grievances, Appeals and in some
circumstances the Administrative Law Hearing.
1. Definitions:
a. Complaint- as expressions of dissatisfaction about any matter other
than an Action that are resolved at the point of contact rather than
through filing a formal Grievance;
b. Grievance- is the procedure for filing an expression of dissatisfaction
about any matter other than an Action
c. Action- 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; the denial, in whole or in
part, of payment for a service; the failure to provide services in a timely
manner, as defined by this Contract; The failure of the Contractor to
act within the timeframes provided in 42 CFR 438.408(b)
d. Appeal- is the request for review of an Action.
e. Administrative law Hearing- The appeal process administered by the
Government of Puerto Rico and as required by federal law, available to
Enrollees after they exhaust the Contractor’s Grievance System and
Complaint Process.
2. Complaints process (APS-PR) has established a process for receiving and
handling complaints which a complainant may have about an aspect of the
APS-PR’s operation, such as dissatisfaction with plan administration; appeal
of an Adverse Determination; the denial, reduction or termination of a service;
the way a service is provided; or disenrollment decisions. APS-PR follows a
consistent procedure in responding to complaints including the following:
a. A beneficiary or its authorized representative shall file a complaint
within 15 calendar after the date of occurrence;
b. Filing of a compliant may be orally or in written;
c. APS-PR will resolved the compliant in 72 hours or less;
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d. The resolution notice shall include the right to file a grievance or
appeal and information on how the member can request for an
administrative law hearing.
3. Grievances- a beneficiary or its authorized representative may file a
grievance through APS-PR or the Health Advocate Office of Puerto Rico,
either orally or in written. A provider may file a grievance on behalf of a
beneficiary only when the enrollee has granted written consent to do so.
APS-PR follows a consistent procedure in responding to grievances including
the following:
a. The grievance has to be filed within 60 calendar days after the event.
APS-PR may extend this timeframe by up to 14 calendar days;
b. The grievance will be responded no later than 30 calendar days from
the date it was received. If the grievance involves a minor, the
timeframe is 20 days.
c. After the investigation is performed, a notice of resolution is issued
containing the basis for the resolution.
4. Appeals process- It involves a formal petition by an Enrollee, an Enrollee’s
Authorized Representative, or the Enrollee’s Provider, acting on behalf of the
Enrollee with the Enrollee’s written consent, to reconsider a decision (an
action). There are two kinds of appeal that can be requested: expedited
appeals or standard appeals:
a. Expedited appeals- shall be resolved in 72 hours since it was
requested. The expedited appeal resolution timeframe can be granted
to the enrollee based on the information provided or when the provider
indicates (when filing the appeal on behalf of the enrollee) that taking
the time for standard resolution could seriously jeopardize the
enrollee’s health or ability to attain, maintain, or regain maximum
function. An expedited appeal may be filed orally and verbally. The 72
hours resolution timeframe may be extended for up to 14 calendar
days;
b. Standard Appeals- shall be resolved no later than 45 calendar days
since it was requested The 45 calendar days resolution timeframe may
be extended for up to 14 calendar days.
APS-PR follows a consistent procedure in responding to appeals including
the following:
c. The Enrollee, the Enrollee’s Authorized Representative, or the Provider
acting on behalf of the Enrollee with the Enrollee’s written consent,
may file an Appeal to the Contractor during a period no less than
twenty (20) Calendar Days and not to exceed ninety (90) Calendar
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Days from the date on the APS-PR Notice of Action or Notice of
Adverse determination;
d. The provider acting on behalf of the Enrollee with the Enrollee’s written
consent will be given an opportunity to present evidence and
allegations in writing. In those cases in which the appeal is requested
by the Provider acting on behalf of the enrollee, the APS-PR Appeals
Coordinator shall ensure the provider submits a form of consent
completed an sign by the enrollee before proceeding with the appeal.
This is regardless it is an expedited or a standard appeal.
e. APS-PR shall provide written notice of all appeals resolution. Such
notice shall include the following information:
i. The right to request an Administrative La Hearing;
ii. How to request and Administrative Law Hearing;
iii. The right to continue to receive benefits pending the
Administrative Law Hearing;
iv. How to request the continuation of benefits; and
v. Notification that if the APS’s-PR action is upheld in a hearing,
the enrollee may be liable for the costs of any continued
benefits.
5. Administrative Law Hearing- the ASES may grant an Administrative Law
Hearing if the enrollee or the providers acting on behalf the enrollee requests
it regardless the APS-PR appeal process has been used. The process
applicable to the Administrative law Hearing are govern by the following
steps:
a. If the enrollee (or the provider acting on behalf of the enrollee with its
written consent) file an appeal of an action with APS-PR first, ASES
will allow an Administrative Law Hearing not less than 20 calendar
days and no later than 90 days from receipt of the APS-PR appeal
resolution notice;
b. If the enrollee seeks for an Administrative Law Hearing without
recourse to the APS-PR appeal process, the ASS will allow it as
expeditiously as the enrollee’s health requires it, but no later than 3
calendar days after the ASES receives directly from the enrollee a
hearing request on a decision to deny a service, when it is determined
by the ASES that taking the time for a standard resolution could
seriously jeopardize the enrollee’s life or health or its ability to attain,
maintain, or regain maximum function;
c. The decision issued by the ASES as a result of the Administrative Law
Hearing is subject to appeal before the Court of Appeals of the
Commonwealth of Puerto Rico.
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Appeal process for Medicare Advantage and Commercial Behavioral Health Insurance
Plan Appeals
In the case of Medicare Advantage and Commercial BH Health Plans, APS-PR will
adhere to the standards established by the Centers for Medicaid and Medicare Services
(CMS) for handling appeals. This means that APS-PR will make timely handle and
process appeals based on the standard and expedited timeframes established by CMS.
An Appeal is the request for review of an APS-PR adverse determination. It is a formal
petition by an Enrollee, an Enrollee’s Authorized Representative. If a provider wishes to
appeal a standard pre-service determination, he/she may do so if such appeal is based
on a difference of a clinical nature and not for refusing to follow APS-PR processes.
Appeals made by the provider on behalf of a beneficiary must be made in writing and
must be made after acquiring the beneficiary’s written consent.
Additionally,
beneficiaries who submit expedited requests or facilities that submit expedited requests
on behalf of the beneficiary must send APS-PR a written signed request for appeal. A
party may request a standard reconsideration by filing a signed, written request with the
APS-PR.
A member or the provider acting as the members appointed representative will have a
period of sixty (60) days from the date of the notice of the organization determination
sent by APS-PR to submit the corresponding appeal.
The provider acting on behalf of the Enrollee with the Enrollee’s written consent will be
given an opportunity to present evidence and allegations in writing.
Upon reconsideration of an adverse organization determination, APS-PR will make its
determination as expeditiously as the enrollee’s health condition requires. This must be
no later than thirty (30) calendar days from the date APS-PR receives the request for
standard reconsiderations (appeals). The time frame will be extended by up to 14
calendar days by APS-PR if the enrollee requests the extension or if APS-PR requires
additional information and documents how such delay is in the interest of the enrollee.
Hospitals are required to provide APS-PR access to obtain all necessary medical
records and other pertinent information within the required time limits to resolve the
appeal.
APS-PR will mail an acknowledgement letter to the enrollee to confirm the facts and
basis of the appeal, and request that the enrollee sign and return the acknowledgement
letter. The letter must explain that until the acknowledgement letter is returned, no final
decision can be issued;
APS-PR will not issue a final decision on the appeal until it receives the signed
acknowledgement letter, or other signed document relevant to the appeal request; and
If APS-PR does not receive a returned, signed acknowledgement by the conclusion of
the appeal timeframe, plus extension, it will forward the case to the independent review
entity with a request for dismissal (if applicable).
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An enrollee or any physician may request that APS-PR expedite a reconsideration
(appeal) of a determination, in situations where applying the standard procedure could
seriously jeopardize the enrollees life, health, or ability to regain maximum function. In
light of the short time frame for deciding expedited reconsiderations, a physician does
not need to be an authorized representative to request an expedited reconsideration on
behalf of the enrollee. A request for payment of a service already provided to an
enrollee is not eligible to be reviewed as an expedited reconsideration.
If APS-PR denies a request for an expedited reconsideration, it must automatically
transfer the request to the standard reconsideration process and then make its
determination as expeditiously as the enrollee’s health condition requires, but no later
than within 30 calendar days from the date the appeal was received. APS-PR shall
provide the enrollee with prompt oral notice of the denial of the request for
reconsideration and the enrollee’s rights, and subsequently mail to the enrollee within 3
calendar days of the oral notification, a written letter.
If the Medicare health plan approves a request for an expedited reconsideration, then it
must complete the expedited reconsideration and give the enrollee (and the physician
involved, as appropriate) notice of its reconsideration as expeditiously as the enrollee’s
health condition requires, but no later than 72 hours after receiving the request.
To properly submit an appeal on behalf of a beneficiary the hospital or facility will be
required to contact one of our Appeals Coordinators at (787) 503-7929, Extensions
193035 or 193079.
C. RETROSPECTIVE-REVIEW
Retrospective reviews are defined as a review conducted after services have been
provided to the patient. These reviews are conducted when a patient has received
treatment without authorization, or when the pre-certification by a contracted provider or
facility was not feasible, the provider is not contract by APS-PR (this happens mostly
when the services are furnished out of the services area). The APS-PR Appeals
Coordinator facilitates all retrospective reviews.
In the case of a patient who has been discharged from inpatient care and no precertification has occurred, an administrative/contractual non-certification determination will
be made. A review for medical necessity may occur if the written appeal indicates the
provider could not determine if the patient had insurance requiring pre-certification. When
the patient remains in treatment, an administrative / contractual non-certification is made
for the days prior to the call for authorization and a care manager begins ongoing reviews
of the case with the provider for continuing stay criteria. An administrative/contractual
non-certification applies to claims generated appeals, calls for pre-certifications outside
the contractual limitations and cases where the patient is discharged and the facility
decides to call APS-PR for authorization. All care managers can approve services when
the APS-PR criteria are met. When there is doubt or question as to whether a patient
meets the criteria for the requested level of care, the physician advisor / peer reviewer is
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contacted to review the case and to determine if there will be a non-certification of the
requested services. In all non- certification cases, the provider is offered an alternative
treatment option and receives instructions regarding the appeals process. If the
retrospective review is with regard to outpatient treatment, the patient’s medical record
also undergoes a review with a determination.
When the pre-certification of the patient was outside the timelines for pre-certification,
the case is administratively / contractually denied. The provider may appeal this
decision, which requires he/she to submit the complete medical record for review. An
initial review of the medical record is completed by the Appeals Coordinator with
supervision by a clinician, if necessary; to ensure that there is no medical necessity
issues involved that warranted being out of the pre-certification time line. The record is
then submitted to administration for a benefits / contract review to again ensure the
appropriateness of the administrative / contractual denial.
[ V ] CLAIMS DEPARTMENT
The claims system is an on-line adjudication system that is fully integrated with all
supporting files necessary for validation and extraction of key data elements vital to
quick and accurate claims payment. During the on-line adjudication process, the
system is able to automatically access the membership, benefits, authorization and
provider files in a matter of seconds, requiring manual intervention only if an error
situation occurs. In addition, all codes (ICD9, DSM IV TR, CPT and Revenue Codes)
are validated against code file tables to maintain the integrity of the data. Further, the
adjudication process edits each claim transaction line against the claims transaction file
to detect any possible duplicate transactions. Since all processing occurs in a real time
on-line environment, accurate, up-to-the-minute information is available continuously.
APS-PR also utilizes scanning and an automatic adjudication process to streamline the
administrative work associated with claims handling. This technology allows a scanned
claim to automatically adjudicate in the same manner as a paper claim. When normal
adjudication edits occur, the claim is pended for manual review.
A. CLAIMS QUALITY MEASUREMENT PROGRAM
Claims Accuracy – Selection Criteria
The claims system allows us to select claims to audit for accuracy according to two
different sets of criteria: random selection and dollar amount. For each claims
examiner, an employee file is maintained in the processing system that allows us to
designate the number of claims randomly selected for auditing and a specific payment
dollar amount for which all claims with payment amounts at or above that amount will be
selected for auditing. The number of claims randomly selected for audit is based on the
experience level and performance of the individual examiner. Throughout the
department, all claims with payment amounts of $1,500 or more are selected for
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auditing. Claims selected for auditing are held in a suspended status until they are
reviewed and released by an Auditor or a Supervisor.
1. Measurement Methods
Claims selected for audit are thoroughly reviewed for accuracy. Errors found during the
review process are classified according to two categories: payment and non-payment.
Payment errors are those errors that would affect the payment of the claims in any way.
Non-payment errors are those errors that would not affect the payment of the claims.
This data is then used in the following manner to measure claims accuracy:
2. Payment Error
Percentage Number of claims that contained payment errors divided by the number of
claims sampled.
3. Overall Error
Percentage Number of claims that contained both payment and non-payment errors
divided by the total number of claims sampled.
During the auditing, all errors are captured, categorized and discussed with the Claims
Examiner. However, for measuring purposes, each claim that contains multiple errors is
counted as either a payment error claim or a non-payment error claim, with payment
errors always taking precedence over non-payment errors.
Our standards for accuracy are 98% Payment Accuracy and 95% Overall Accuracy.
B. REIMBURSEMENT PROCEDURES
1. Collection of Co-payment
Members typically have a co-payment or co-insurance obligation for behavioral health
care services. The APS-PR Customer Service Representative will inform the provider
of the member’s co-payment amount when the referral is made. It is the provider’s
responsibility to collect the member’s co-payment at the time of service. The remainder
of the provider’s contracted fee will be reimbursed by APS-PR.
If a member refuses to remit the co-payment to a provider, the provider is to contact the
Customer Service Department at APS-PR. APS-PR will attempt to resolve the situation
so that the member may receive services. Members who have questions concerning
their financial responsibility in the provision of behavioral health care services should be
directed to contact APS-PR’s Customer Service Department.
2. Balance Billing
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Under federal law, HMO members cannot be billed for moneys due from an insurer for
covered services. In contracting with APS-PR, a provider agrees that the collection of
the member’s co-payment or co-insurance is his/her responsibility and that he will not
bill the member in excess of this amount.
The only time you may submit a bill to a APS-PR member is if you have obtained prior
written acknowledgment from your client/patient that you will be engaging in a treatment
plan that is either not covered by the plan or not authorized as medically necessary by
APS-PR.
3. Waiver of Co-payment
(a) It is APS-PR policy to adhere to our client’s non-waiver of co-payment guidelines.
As such, APS-PR will not waive a member’s co-payment or coinsurance
responsibility under any circumstances.
(b) We subscribe to the trend in the healthcare industry toward the consumer’s
awareness of their own health care expenditures by requiring a shared financial
responsibility between enrollees and health care payers. This trend is seen in the
shift from employers who provide full health insurance coverage to that of employers
purchasing benefit packages in which employees are contributing a larger portion of
their health care costs.
(c) APS-PR providers may independently waive the co-payment or coinsurance
responsibility of any member. A decision to waive members financial contribution to
the services provided is neither sanctioned nor prohibited by APS-PR. In such a
case, APS-PR will reimburse the provider at the contracted rate for the service
provided less the co-payment or coinsurance amount.
4. Submission of Claims
To ensure timely processing, complete patient and provider information should be
submitted with all claims. The HCFA 1500 is to be used for outpatient services and the
UB-92 should be used for the submission of all institutional claims. The address of the
payor for each member’s benefits will be listed on the identification card. Submit all
claims to the appropriate address within ninety (90) days of the date of service or date
of discharge. Submit claims to the following address:
APS Healthcare Puerto Rico, Inc.
Claims Department
P.O. Box 71474
San Juan, PR 00936-8574
When submitting claims to APS-PR, it is requested that regular charges are billed.
APS-PR will pay for authorized covered services, less the co-payment or coinsurance
amount, at the rate listed on the provider’s agreement or billed charges, whichever is
lower.
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All HCFA 1500s and UB92s should contain standard required information. To speed
the processing of claims, please follow the guidelines listed below:
All Claims
• Member name and ID Number as they appear on the member’s ID card.
• CPTIV Code or Revenue Code that corresponds to the services included in your
provider contract.
• The APS-PR authorization number should be listed in box 23 of the HCFA 1500 and
box 63 of the UB92.
• Complete information concerning other insurance
• The Tax Identification Number of the group, facility, or individual that holds the
contact with APS-PR and has been authorized to render the services being billed.
Providers contracted with APS-PR as a member of a group practice must bill with
the Tax Identification Number of the group practice and not their individual social
security number.
5. HCFA 1500 Instructions:
HCFA 1500s are sent through a Scanning Process using Optical Character
Recognition. This process can allow us to significantly reduce processing time if the
claims documents are completed according to the following guidelines.
• Red and White forms only
• Typewritten data with dark print
• Data must be correctly printed within the boxes
(Data that is not aligned correctly, or when multiple data elements appear in a box
designed for one, the claim cannot be scanned.)
• The provider address must appear correctly in box 33.
• Rendering provider name must appear correctly in box 31. A signature may also
appear in this box.
• Cannot be marked with any rubber stamps or contain any handwritten information
outside of boxes, 12, 13, (patient/member signatures) and 31 (rendering provider
signature.)
6. Coordination of Benefits
Coordination of benefits (COB) guidelines are used by APS-PR to arrange
payment when an individual is covered under more than one group health
policy. The first determination of the primary insurer is based on the
employee relationship. The policy held by a person through their employer
for that person.
for claims
insurance
employeris primary
When dependent children of married parents are covered under more than one policy,
APS-PR follows the guidelines of the National Association of Insurance Carriers (NAIC),
which recommend using the “birthday rule” to determine primary coverage. This rule
states that the policy of the parent whose birthday falls first in the calendar year, using
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month and day only, is primary for the children. When both parents have the same
birthday, the primary insurance carrier is determined by the policy effective date.
When dependent children of divorced or separated parents are covered under more
than one group health policy, the following order is used to determine the sequence in
which benefits are paid:
1)
2)
3)
4)
the policy of the parent with custody of the children;
the policy of the spouse of the parent with custody of the children;
the policy of the non-custodial parent;
the policy of the spouse of the non-custodial parent.
If it is determined that APS-PR is the responsible party as a secondary payor, an
authorization for services is still required in order for APS-PR to reimburse the
provider for services rendered.
Medicare covers medical expenses as the primary carrier for retired persons over age
sixty-five (65), disabled individuals and persons with End-State Renal Disease (ESRD).
Medicare is typically the primary carrier for Medicare beneficiaries over age 65.
However, there are situations, working aged beneficiaries and certain ESRD patients,
when the typical rules do not apply. Please contact APS-PR customer service if you
need assistance in determining if Medicare is the primary or secondary carrier.
When Medicare is the primary carrier, APS-PR will reimburse providers for any
applicable deductible and coinsurance. Once the deductible is met, Medicare Part A
covers inpatient hospital services, home health services and institutional services.
Medicare Part B covers eighty percent (80%) of the allowed amount for physicians
services and other outpatient services. All other State and Federal laws governing COB
are followed even if not explicitly stated here.
7. Claims Payment Appeals
Should a provider disagree with the manner in which a claim was paid or the reason for
a denial of payment, the provider may appeal to APS-PR. When submitting an appeal,
all pertinent information and a written request is to be sent to APS-PR at the following
address:
APS Healthcare Puerto Rico, Inc.
P.O. Box 71474
San Juan, PR 00936-8574
Phone: (800) 503-7929 ext. 3015
Appeals are to be filed within ninety (90) days of the date the claim was originally
processed. A response will be sent to the provider within thirty (30) days of receipt of all
information necessary to review the appeal.
.
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8. Missed Appointments/No-Shows
A member may not be charged for canceled appointments if the member has provided
at least twenty-four (24) hours notice of cancellation. The office policy of the provider
on canceling appointments should be communicated to members at the
commencement of treatment. A provider may only collect a co-payment from a member
who cancels an appointment without twenty-four (24) hours notice or who fails to give
any notice at all (no-show). Missed appointments and no-shows do not count against
APS-PR member’s maximum benefit allowance and APS-PR assumes no liability for
the collection of such charges. The collection of charges from members who have
benefit plans that are not managed by APS-PR is determined by the payor. The payor’s
telephone number, listed on the member’s identification card should be called to
determine reimbursement in these cases.
NOTE: This does not apply to MiSalud members may not be charged for canceled
appointments.
C. MEMBER HOLD HARMLESS PROVISION
1. Charges to APS-PR Members
Providers and Physicians agree to collect applicable co-payments, if any, from
Members at the time services are provided by the Provider or Physician. The Provider
and Physician shall look only to APS-PR for compensation for Necessary Covered
Services. In addition, Provider and Physician shall under no circumstances, including
the termination of the existing Agreement or the insolvency of APS-PR or breech of the
existing Agreement, assert any claim for compensation against Members or persons
acting on their behalf for Covered Services in excess of applicable co-payments.
Providers and Physicians agree to provide continuation of services until discharge of
any Members confined in an inpatient facility on the date of insolvency or other
cessation of operations or through the premium-paid period for which member has
made prepayment, or on whose behalf prepayment has been made. Provider and
Physician further agree that this provision shall survive the termination of the existing
Provider Agreement regardless of the cause giving rise for termination and shall be
construed to be for the benefit of the APS-PR Member/enrollee, and that this provision
supersedes any oral or written contrary agreement now existing or hereafter entered
into between Provider and/or Physician and Member, enrollee, or persons acting on
their behalf.
2. Explanation of Benefits (EOB)
With every APS-PR check, an Explanation of Benefits (EOB) report is issued. An
example of the Explanation of Benefits is included as an attachment to this manual.
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[ VI ] QUALITY IMPROVEMENT PROGRAM
I.
Purpose and Goals
This document describes the scope, structure and function of APS-PR behavioral health
quality improvement program. The purpose of the quality improvement program is to
provide the operational structure and processes necessary to achieve the goals and
objectives established by the APS-PR Board of Directors and other quality oversight
committee.
II. Structure of the Quality Improvement Program
A. Authority and Responsibility
The APS-PR Board of Directors are the ultimate authority and accountability for the
quality of care and service delivered to health plan division enrollees, and is the highest
level of oversight for the quality improvement program. The APS-PR Boards of
Directors delegate their oversight responsibilities to the APS-PR Corporate Quality
Improvement Committee (CQIC).
The APS-PR CQIC delegates operational
responsibility for the HPD quality improvement program to the Health Plan Quality
Improvement Committee (HPQIC).
B. Designated Behavioral Health Care Practitioner
The implementation of the HPD’s quality improvement process is under the direction of
the Corporate Medical Director, Quality Improvement. The Corporate Medical Director,
Quality Improvement delegates day to day implementation of the health plan division’s
QI program to the Corporate Director, Behavioral Health Quality Improvement. He or
she is responsible for:
•
•
•
•
•
The oversight of the implementation of the QI Work plan.
Supporting the QI committee structure in conducting its activities.
Tracking identified opportunities for improvement.
Facilitating and supporting all areas in data collection and analysis, as well as
in designing interventions.
Providing leadership and training in completing external regulatory and
accreditation reviews.
The Corporate Director of Behavioral Health Quality Improvement is a licensed,
behavioral health practitioner.
C. Input from Medical Delivery Systems
The APS-PR HPD includes input and representation from medical delivery systems in a
number of ways. These include:
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•
•
•
•
Participation in Managed Care Organization (MCO) partners QI Committee
activity.
Regular QI workgroups with MCO and APS-PR QI staff.
Joint development and implementation of prevention and clinical improvement
programs.
Annual oversight audits by MCO partners. During these audits MCOs make
recommendations and develop action plans as appropriate with APS-PR.
This input from MCOs is documented in appropriate committee minutes and focuses on
both clinical and service improvement activities.
APS-PR Board of Directors
The APS-PR Healthcare Board of Directors is APS-PR governing body and provides
oversight and direction to the QI Program. At least five of the Directors are nonemployees of APS-PR. The APS-PR Board of Directors’ membership is composed of:
•
•
•
•
Chief Executive Officer, APS-PR
Chief Financial Officer, APS-PR
APS-PR Legal Counsel
Directors from External Organizations (5)
The APS-PR Board of Directors meets on a quarterly basis, maintains minutes of its
meetings and annually reviews and approves the health plan division’s QI Program
Description. The APS-PR Board of Directors has delegated oversight responsibility of
the HPD QI Program to the APS-PR Corporate Quality Improvement Committee.
However, the APS-PR Board of Directors retains the final responsibility for the health
plan division’s operations and performance.
1. APS-PR Corporate Quality Improvement Committee
Reports to: APS-PR Board of Directors and CNR Health Partners Board of Directors
Reporting Process: Annual submission of Health Plan Division Behavioral Health QI
Program Description
Meeting Frequency: At least quarterly.
Membership:
• Vice President, Corporate Quality Improvement (Chair)
• President, Behavioral Health
• Vice President, Clinical Services
• President, Health Plan Division
• President, Employee Assistance Programs
• President, Employer Division
• Medical Director, Health Plan Division
• Corporate Medical Director, Quality Improvement
• Vice President, Medical Services
• APS Legal Counsel
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•
•
•
•
•
•
•
•
•
•
•
•
Chief Information Officer
Corporate Director, Behavioral Health Quality Improvement
Corporate Director, Credentialing
Executive Vice President, Sales and Marketing
Chief Executive Officer, APS-PR
Vice President, Operations - APS Northwest
Vice President, Public Sector Operations
Vice President, Behavioral Health Services - APS Wisconsin
Executive and Medical Director - APS Hawaii
Chief Information Officer
Vice President, Marketing
Chief Financial Officer
Roles and Functions of Committee: The functions of this committee include the
following:
• Annually review and approve the QI Program Descriptions from each APS-PR
division.
• Annually review and approve the QI Work Plans and the annual evaluation of the QI
Programs from each APS-PR division.
• Oversee all quality improvement activities of subcommittees.
• Monitor allocation of resources needed to achieve APS-PR quality improvement
goals.
• Annually review and approve the Utilization Management Program documents and
Utilization Management Review Criteria from each APS-PR division.
• Provide final approval of clinical guidelines.
At least 50% of the voting members are required for a quorum. A simple majority of
voting members present is required for approvals.
2. APS Policy and Procedure Committee
Reports to: APS Corporate Quality Improvement Committee
Reporting Process: Submission of written, approved minutes by the committee chair.
Verbal presentations of subcommittee recommendations, reports, and policy activities.
Verbal presentations and written reports as required.
Meeting Frequency: At least four times per year
Membership:
• Vice President, Corporate Quality Improvement (Chair)
• Manager, Quality Improvement - Health Plan Division
• Manager, Quality Improvement - APS Hawaii
• Manager, Quality Improvement - APS Medical Services
• Director, Quality Improvement - APS Puerto Rico
• Coordinator, Quality Improvement - APS Wisconsin
• Medical Director - APS Northwest
• APS Legal Counsel
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Roles and Functions of Committee: The functions of this committee include the
following:
• To develop and approve processes for the development and adoption of policies and
procedures throughout APS-PR.
• To review and approve corporate-wide policy and procedures.
• To ensure the annual review and revision, when needed, of APS-PR policies and
procedures.
• To develop and maintain an organized system of tracking and storing policies and
procedures.
• To ensure that staff receive training on policies relevant to their job duties.
4. APS Chief Privacy Officer
The APS Privacy Officer has the primary responsibility for ensuring that the enterprise’s
privacy policies and procedures are accurate and, as appropriate, are integrated into
the operations of the Business Units.
Roles and Responsibilities of the APS Chief Privacy Officer
The APS Chief Privacy Officer has the following responsibilities:
• Creating and developing privacy policies and procedures.
• Arranging for responses to all employee questions concerning privacy issues that
may or may not be readily answered from this policy.
• Directly or through designees, receiving, documenting, and taking action in response
to any complaints made by customers, employees or any other individuals regarding
APS’s privacy practices and procedures.
• Developing training programs and materials that educate employees on the policies
and procedures for safeguarding the privacy of PHI.
• Maintaining the accuracy of the enterprise’s privacy policies. This includes
reviewing federal and state laws and regulations and changing the APS-PR policies
and procedures as necessary and appropriate to comply with changes in the law.
• Maintaining the accuracy of the Notice of Privacy Practices as set forth in the APSPR Notice Policy. If a privacy practice that is described in the Notice of Privacy
Practices changes, the Privacy Officer must direct and oversee a change in the
Notice of Privacy Practices.
• Developing and approving mechanisms to oversee the application of privacy
policies.
• Identifying opportunities for reducing collection of unnecessary enrollee data or deidentifying data as close to its source as possible.
• Approving levels of authorized use and access to data across the delivery system.
• Reviewing and approving/denying both internal and external requests to use
enrollee data.
• Facilitating an appeals process to address enrollee concerns regarding
confidentiality of data.
• Overseeing mechanisms for adhering to specific requests to limit access to data.
• Approving research projects that involve the release of enrollee data.
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5. ASP PR Quality Improvement Committee
Reports to: APS Corporate Quality Improvement Committee
Reporting Process: Submission of written, approved meeting minutes on a quarterly
basis. Submission of a QI program, work plan and evaluation on annual basis. Verbal
presentations and written reports as required.
Meeting Frequency: At least quarterly
Membership:
• Medical Director (Chair)
• Director Quality Improvement
• President and Chief Executive Officer
• Chief Clinical Officer
• Clinics Director
• Appeals Coordinator (Non-voting staff)
• Client Services Specialist (Non-voting staff)
• Pharmacy Director
• Providers Director
• Senior Member Referral (Non-voting staff)
• UM Manager
Roles and Responsibilities of APS-PR QIC
• Annually review and approve the APS-PR Behavioral Health QI Program
Description.
• Annually review and approve the evaluation the effectiveness of the PR
implementation of its QI program and the QI Work Plan.
• Annually review and approve the APS-PR Behavioral Health Utilization Management
Program documents and adopt the APS-PR Behavioral Health Utilization
Management Review Criteria.
• Oversee all quality improvement activities of committee subcommittees as specified
in the PR Quality Improvement Work Plan.
• Monitor the findings of the clinical and service performance measures and
implement corrective actions for improvement.
• Oversee continuity and coordination of care activities.
• Recommend decisions on content of APS-PR policies and procedures.
• Review results of satisfaction surveys and other performance studies. Identify and
prioritize opportunities for improvement. Develop action plans or QI activities based
on study results.
• Ensure adequate resources and training are in place to support the QI program.
• Ensure compliance with state, federal and external accrediting bodies.
• Provide final review and oversight of delegated activities.
• Identify potential clinical measurement activities that are relevant to the health plan
division’s enrollees.
• Develop clinical monitors and data collection specifications.
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•
•
•
•
•
•
•
•
•
•
•
Review and analyze data related to clinical quality measurement activities, including
clinical studies, clinical practice guidelines and preventive behavioral health
programs.
Identify opportunities for improvement.
Develop and oversee the implementation of interventions related to clinical quality
improvement activities.
Provide input and recommendations to the HP QIC related to clinical quality
improvement activities.
Identify potential service measurement activities that are relevant to the health plan
division’s enrollees and practitioners/providers.
Develop data collection strategies and tools to evaluate enrollee and
practitioner/provider satisfaction.
Review and analyze data from satisfaction surveys, complaints and appeals.
Review and analyze data related to availability and accessibility monitoring activities.
Identify opportunities for improvement.
Develop and oversee the implementation of interventions related to service quality
improvement activities.
Provide input and recommendations to the PR Quality Improvement Committee
related to service quality improvement activities.
At least 50% of the voting members are required for a quorum. A simple majority of
voting members present is required for approvals.
6. Utilization Management Committee
Reports to: PR Quality Improvement Committee
Reporting Process: Submission of written, approved minutes by the committee chair.
Verbal presentations of subcommittee recommendations, reports, and service activities.
Verbal presentations and written reports as required.
Meeting Frequency: At least quarterly
Membership:
• Medical Director, Chair
• Chief Executive Officer
• Chief Clinical Officer
• Clinical Services Director/Clinics
• QI Director
• UM Manager
• Member Referral Supervisor
• Pharmacy Department Director
Roles and Functions of Committee: The functions of this committee include the
following:
• Annually, review and revise the APS-PR Behavioral Health Utilization Management
Program and Behavioral Health Utilization Management Review Criteria
• Develop the annual UM Work Plan and UM Evaluation for PR Division.
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•
•
•
Provide input and make recommendations on utilization management policies and
procedures.
Identify opportunities to improve utilization management processes and support
implementation of improvement activities.
Regularly review and monitor data related to key utilization management indicators.
At least 50% of the voting members are required for a quorum. A simple majority of
voting members present is required for approvals.
7. Provider Advisory Group
The Provider Advisory Group (PAG) provides for structured input from external
practitioners to be utilized in the development and implementation of the behavioral
health QI program and activities for the APS-PR. The APS-PR PAG members are
drawn from a variety of APS-PR’ networks where APS-PR has health plan business.
Practitioners participate via teleconference.
Reports to: The PR Quality Improvement Committee
Reporting Process: Submission of written meeting minutes on a quarterly basis.
Verbal presentations and written reports as requested.
Meeting Frequency: At least quarterly
Membership: Practitioners/providers represent medical delivery systems and
behavioral health specialties from the following:
• Medical Director (Chair)
• Provider’s Director
• Quality Improvement Director
• Psychiatrist
• Psychologist
• Social Worker
• Substance Abuse Provider
Roles and Functions of Committee: The functions of this panel include the following:
• Support the development of appropriate clinical practice guidelines and guideline
monitoring.
• Review and make recommendations regarding requests for new technology.
• Review APS-PR policies and procedures and make recommendations as they relate
to the practitioner community.
• Provide input in the development and review of APS-PR utilization management
criteria.
• Provide clinical input into the development of appropriate preventive health and
other quality improvement programs.
• Provides input on continuity and coordination of behavioral healthcare.
• Evaluate and provide feedback on the results of provider satisfaction survey
activities.
• Assist in developing provider education and communication processes and tools.
• Serve as consultants to APS-PR representing practitioner viewpoints and concerns.
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8. Member Advisory Panel
APS-PR has a Member Advisory Panel (MAP) that provides input and feedback on
quality and service activities to both operations centers’ quality committees. The MAP
consists of enrollees from a variety of sites where APS-PR manages behavioral health
accounts. APS-PR quality improvement staff facilitates the meetings. As needed, APSPR can procure additional feedback from the panel members related to specific clinical
and service issues through focused mailings.
Reports to: PR Quality Improvement Committee.
Reporting Process: Submission of written minutes for each meeting, to include
documentation of Member Panel feedback/focused input.
Meeting Frequency: At least twice a year. Other feedback procured by structured and
focused mailings on an as needed basis.
Membership:
The membership for the MAP includes behavioral health enrollees chosen from various
APS-PR sites where health plan business is managed.
Roles and Functions of Committee: The functions of this panel include the following:
• Provide consumer input into the QI process.
• Assist in identifying key quality indicators affecting consumers.
• Review and make recommendations around preventive behavioral health programs.
• Review and make recommendations regarding routine correspondence directed to
members for clarity, readability and utility.
• Provide comments on the results of consumer satisfaction surveys and outcome
studies.
• Review and make recommendations regarding APS-PR policies and procedures as
they relate to consumers.
• Serve as consultants to APS-PR representing member viewpoints and concerns.
9. Credentialing Committee
Reports to: APS-PR Quality Improvement Committee
Reporting Process: Submission of written minutes approved by the committee chair.
Verbal and written presentation of recommendations for credentialing and recredentialing decisions for network participation to the HP QIC.
Meeting Frequency: At least monthly
Membership:
• Medical Director (Chair)
• Network Practitioner: Psychiatrist
• Network Practitioner: Psychologist
• Network Practitioner: Child and Adolescent Practitioner
• Network Practitioner: Social Worker/Other Masters-level
• Network Practitioner: Substance Abuse Counselor
• Network Practitioner: Inpatient Practitioner
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•
•
•
Corporate Director, Credentialing (non-voting member)
Credentialing Supervisor (non-voting staff)
Provider Director (non-voting staff)
Roles and Functions of Committee: The functions of this committee include the
following:
• Oversee and conduct the credentialing and recredentialing of practitioners and
providers, and conduct peer review and approval of credentialing status to network
practitioners and providers.
• Credential provider entities, such as inpatient facilities.
• Make recommendations on content of credentialing policies and procedures for
practitioners and providers.
• Review quality of care issues related to individual practitioners or providers and
make recommendations as appropriate.
• Review and approve oversight activities related to delegated credentialing
arrangements.
10. Practitioner Appeals Committee
Reports to: APS-PR Quality Improvement Committee
Reporting Process: Submission of written minutes approved by the committee chair.
Verbal and written presentation of recommendations related to appeal outcome.
Meeting Frequency: As needed basis
Membership:
• Medical Director, (Chair, non-voting member)
• At least 3 clinical professionals who are not in direct economic competition with the
practitioner under review. For review of physician practitioners all members will be
licensed physicians. For review of non-physician practitioners at least one member
will be a physician and at least one member will be in the discipline of the
practitioner under review.
• Chief Clinical Officer (non-voting staff)
• Provider Director (non-voting staff)
• Credentialing Supervisor (non-voting staff)
• APS-PR Legal Counsel (non-voting staff)
• Quality Improvement Director (non-voting staff)
Roles and Functions of Committee: The functions of this committee include the
following:
• Complete review of all materials relevant to practitioner appeals related to APS-PR’
modification or termination of network participation.
• Determine appeal outcome to overturn, overturn with conditions or uphold prior
Credentialing Committee decision on practitioners network participation.
III. Program Scope and Content
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The scope of the quality improvement program encompasses the assessment,
monitoring and improvement of all aspects of care and service received by enrollees,
including the following:
• care delivered in inpatient, outpatient and alternative settings at all acuity levels;
• all types of behavioral health care services delivered by all types of practitioners and
providers; and
• services delivered by APS-PR and its contractors.
The APS-PR implements an annual Quality Improvement Work Plan (see Attachment
1). This work plan details the specific activities, objectives and performance standards
encompassed by the current Quality Improvement Program Description. The Quality
Improvement Work Plan includes the specific objectives of the quality improvement
activity, including performance goals or standards, the persons accountable for
coordinating and ensuring the activity is completed, the critical action steps to complete
the activity and the target date for completion of the activity. An overview of these
activities is presented below.
A. Quality Management Methods and Monitors
APS-PR’ quality improvement methods include a four-stage process for identifying and
improving the quality of clinical care and service rendered by APS-PR and APS-PR
practitioners:
• Identification of monitors of important aspects of care and service
• Identification of opportunities for improvement as a result of monitoring clinical
care and service
• Implementation of interventions addressing the identified opportunities for
improvement, and
• Remeasurement to determine if the interventions were effective in improving
clinical cares and service.
B. Clinical Quality Improvement Activities
1. Clinical Studies
a. Improving Follow-up after Behavioral Health Hospitalization
Description: Annual measure of the % of members hospitalized for behavioral
health diagnoses that receive 5, 7 and 30 day follow-up after discharge.
Objective: To improve performance to the rates indicated below:
• Commercial 5 day – 50%
• Commercial 7 day - 65%
• Commercial 30 day-70%
• Medicaid 5 day - 60%
• Medicaid 7 day – 70%
• Medicaid 30 day- 85%
• Medicare 5 day – 45%
• Medicare 7 day –50%
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•
Medicare 30 day-65%
b. Improving Appropriate Antidepressant Medication Management
Description: Annual measurement of the following:
• % of enrollees with depression on antidepressant medication that had at least 3
follow-up contacts
Objective: To establish a baseline rate for the monitor above and identify an
opportunity for improvement as appropriate:
Description: Annual measurement of the following:
• % of enrollees with depression on antidepressant medication that remained on
the medication for 12 weeks.
Objective: To measure the rates indicated below:
Description: Annual measurement of the following:
% of enrollees with depression on antidepressant medication that remained on
the medication for 6 months
•
Objective: To measure the rates indicated below:
c. Evaluating the Availability of Psychotherapy and/or Medication Management
for Patients with Schizophrenia
Description: Annual measurement of the % of patients (Medicaid) with
Schizophrenia who were seen by a psychiatrist for medication management or
psychotherapy at least 4 times during the 12 months prior to their last date of service
in the measurement period.
Objective: To establish a baseline rate for the monitor above and identify an
opportunity for improvement as appropriate.
2. Clinical Practice Guideline Monitoring and Improvement
a. The Treatment of Major Depression in Adults
Description: Annual monitoring of the following elements across all products:
• % of patients where the major depression diagnosis met the DSM-IV-TR criteria
for the disorder.
• % of patients with mild or moderate major depression, in treatment with a nonprescribing practitioner, referred for medication evaluation if no improvement
after 6 sessions or 3 months.
• % of patient with severe major depression, in treatment with a non-prescribing
practitioner, referred for medication evaluation after 3 or less sessions.
• % of patients with major depression with psychotic features that were treated
with one of the following: antidepressant plus an antipsychotic medication or
ECT.
• % of patients with major depression and an Axis II diagnosis of a personality
disorder that are receiving psychotherapy.
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Objective: To establish baseline rates for the monitors above and identify any
opportunities for improvement as appropriate.
b. The Treatment of Bipolar Disorder
Description: Annual monitoring of the following elements across all products:
• % of patients diagnosed with bipolar disorder that continue to have psychiatric
management 6 months after initial session or discharge from an inpatient
episode.
• % of patients diagnosed with bipolar disorder that are in psychotherapy for at
least 6 months after the initial session.
Objective:
• To establish baseline rates for the monitors above and identify opportunities for
improvement as appropriate.
3. Preventive Behavioral Health Programs
a. Attention Deficit Hyperactivity Disorder in Children: Parenting Skills Training
Description: Program for parents of children 12 years of age and younger
diagnosed with ADHD. The program goals are to:
• Prevent or minimize stress related symptoms in parents developed as a
consequence of parenting a difficult child.
• Prevent additional psychiatric co-morbidity resulting from dysfunctional parentchild interactions due to ADHD symptoms.
• Reduce the disability associated with ADHD in children.
Objective: To improve the following aspects of the program:
• To increase parent program participation.
• Improve the effectiveness of the program by providing emerging, detailed ADHD
information on an ongoing basis to all parents of children currently in treatment
for ADHD.
b. Education and Treatment Compliance for Adults with Depression
Description: Program for adults diagnosed with depression. The program goals are
to:
• Reduce the length of the symptomatic period through compliance with treatment.
• Reduce the prevalence of major depressive disorder in the population.
Objective: To improve the following aspects of the program:
• To establish program to offer education and treatment compliance for adults with
depression.
• Improve the effectiveness of the program by providing information/materials
about medication topics.
• Evaluate possible methods of expanding the program to reach out to enrollees
not in treatment with screening, referral and educational activities.
• Add access questions to surveys sent to all APS-PR program participants to
complete further analysis on timing of program initiation.
4. Assessment of Continuity and Coordination of Care
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Two types of continuity and coordination of care are monitored: between behavioral
health practitioners and providers, and between behavioral health practitioners and
general medical care
a. Assessing the Exchange of Information Across all Levels of Behavioral Health
Care and between Behavioral Healthcare Practitioners and Provider Types
Description: Assessment of whether behavioral health practitioners and/or
providers forward relevant information to each other.
• Annual clinical treatment record review (elements 34 and 35)
• Annual provider coordination of care chart audits (elements 1-5)
• Annual assessment of clinical guidelines
• Treatment of Depression in Adults (monitor #6)
• Annual assessment of providers’ policies and procedures regarding exchange of
information
Objective: To improve the performance on the following monitors:
• Improvement in practitioners attempting to obtain consent to communicate with
other behavioral health practitioners (Measures #1) to 80%.
• Improvement in providers attempting to communicate and communicating with
other behavioral health practitioners to (Measure #4-60%, Measure #5-80%, and
Measure #6-60%, Measure #7-60%)
b. Assessing Appropriate and Timely Access to Behavioral Health Practitioners
Description: Assessments related to access to and follow-up with practitioners.
• Annual studies to assess access and follow-up with practitioners
• Ambulatory Follow-up of Patients Discharged from the Inpatient Level of Care
with a Behavioral Health Diagnosis
• Antidepressant Medication Management
• Quarterly appointment access monitoring
• Annual assessment of clinical guidelines
• Treatment of Depression in Adults (monitor #15)
• Annual review, revision and training on policies relating to appropriate
referrals for medication management
Objective: To improve the performance on the following monitors:
• Improving the ambulatory follow up of patients discharged from inpatient care
(Measure #9) to 75% within 30 days.
• Improving the attendance to follow-up appointments and medication compliance
for patients on antidepressant medication as determined with each MCO partner.
(Measure #11, #12, and #13)
c. Assessing the Exchange of Information Between Behavioral Health Care
Practitioners, Providers and Primary Care Physicians (PCPs) and other
Medical Providers
Description: Assessment of whether behavioral health practitioners forward
relevant information to PCPs using the following data sources:
• Annual provider coordination of care chart audits
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Annual clinical treatment record review (elements 36 and 37)
Annual assessment of clinical guidelines
• Treatment of Depression in Adults (monitor #5)
• Annual practitioner satisfaction survey (question # 22)
• Annual enrollee satisfaction survey (question # XX)
Objective: To improve the performance on the following monitors:
• #2-% of provider charts with evidence consent was obtained to
communication with PCP or other medical practitioners/providers to 50%
• #3-% of provider charts with evidence of communication with PCP or other
medical practitioners/.providers to 50%
• #4-% of provider charts where communication with PCP or other medical
practitioner/providers took place within 7 days of discharge to 50%.
• #5-% of clinical treatment records with evidence the BH practitioner obtained
consent to communicate with the PCP or other medical practitioner/ provider to
80%.
•
•
d. Management of Treatment Access and Follow-up for Co-Existing Medical and
Behavioral Health Disorders
Description: APS-PR implements the following activities to ensure coordination of
care for members with co-existing health problems:
• Collaboration with MCO care managers for enrollees with co-existing medical
disorders
• Provision of psychiatric consults to patients in inpatient medical beds.
• Assessment of provider policies and procedures regarding exchange of
information.
Objective: To collect data on measures related to this aspect of care coordination.
e. Implementation of a Primary or Secondary Preventive Behavioral Health
Program with Medical Delivery Systems
Description: APS-PR implements the following preventive health programs with its
MCO partners
• Attention Deficit Hyperactivity Disorder in Children: Parenting Skills Training
• Education and Treatment Compliance for Adults with Depression
Objective: To improve the performance on the following monitors:
• #46-To increase the % of MCOs participating in the ADHD program to 20%.
5. Treatment Record Documentation
a. Monitoring of Treatment Records for Compliance
Description: Bi-annual monitoring of treatment records for all high volume
practitioners.
Objective: To improve compliance with the following record keeping standards:
• #8-Consent for treatment forms signed to 80%.
• #15-Assessment of severity and imminence of potential harm to self or others is
completed and documented at least once and then as often as appropriate to
80%.
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•
•
•
•
•
•
#25-Mental status exam is completed that includes assessment and
documentation of the patient’s affect, speech, mood, thought content, judgement,
insight, attention or concentration, memory or impulse control to 80%.
#31-Informed consent for medication is documented and the patient’s
understanding of the treatment plan is documented (prescribing practitioners
only) to 80%.
#34-Treatment record provides evidence of practitioner attempting to obtain
consent to communicate with other behavioral health providers or practitioners to
80%.
#36-Treatment record provides evidence of practitioner attempting to obtain
consent to communicate with primary care physician (PCP) or other ancillary
providers when appropriate to 80%.
#39-For children and adolescents, prenatal and perinatal events are documented
to 80%.
#40-For children and adolescents, complete developmental history is
documented to 80%.
6. Improving Patient Safety
a. Supporting Patient Safety through Monitoring of Clinical Record-keeping
Practices
Description: Bi-annual monitoring of clinical record keeping practices that support
patient safety. The following documentation elements are monitored:
• Medication allergies or adverse reactions (or lack of) are clearly noted
• The medical record is legible
• Assessment of severity and imminence of potential harm to self or others is
completed and tracked.
• Relevant medical conditions are listed, prominently identified and revised.
Objective: To increase the % of records with documentation of
• Medication allergies and adverse reactions to 80%
• Assessment of severity and imminence of potential harm to self or other to 80%.
b. Identifying and Investigating Individual Quality of Care Issues and Adverse
Incidents Impacting Patient Safety
Description: Identify, investigate, resolve and track individual quality of care issues
and adverse incidents that impact patient safety.
Objective: To continue to identify, investigate and resolve individual quality of care
issues within processing standards.
c. Ensuring Patient Education on Medication Side Effects
Description: Annual enrollee satisfaction survey which measures the % of enrollees
reporting that in the last 12 months, they were told of side effects of medications to
watch for.
Objective: To continue to monitor the % of enrollees that report being informed
about medication side effects.
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d. Enrollee Education about Patient Safety Issues
Description: Research, development and distribution of educational articles regarding
patient safety issues in APS-PR enrollee newsletters or other direct enrollee mailings.
Objective: To distribute at least 2 educational articles related to medication safety to
enrollees.
C. Service Quality Improvement Activities
1. Availability and Accessibility
a. Monitoring the Availability of Behavioral Health Practitioners and Providers
Description: Completion of the following activities:
• Measurement of performance against cultural availability needs of the
membership.
• Annual measurement of performance against numeric and geographic
standards for the availability of practitioners and providers.
b. Providing Enrollees with Appropriate Access to Care
Description: Annual assessment of member access to non-life threatening
emergency care, urgent care and routine care.
2. Satisfaction Surveys
a. Enrollee Satisfaction Survey (Medicaid)
Description: APS-PR conducts an annual enrollee satisfaction survey, using the
ECHO tool, measuring overall satisfaction with APS-PR and satisfaction with:
• Services
• Utilization Management Processes
• Accessibility and availability
• Treatment quality
• Patient safety issues
• Continuity and coordination of care
• Cultural availability and accessibility
Objective: To improve performance of the following satisfaction measurements:
• Increase to 85% the satisfaction rate with the APS-PR referral process.
• Increase to 50% the % of enrollees reporting they received information on self
help or support groups.
• Increase to 85% the % of enrollees reporting they were given information about
their rights as a patient.
b. Practitioner Satisfaction Survey (Medicaid, Commercial and Medicare)
Description: APS-PR conducts an annual practitioner satisfaction survey
measuring overall satisfaction with APS-PR and satisfaction with:
• Utilization Management Processes
• Customer Services
• Network
• Provider Relations Services
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PCP communication
Objective: To improve performance of the following satisfaction measurements:
•
•
•
•
•
Improve to 85% satisfaction with the ease of referring to a psychiatrist for an
evaluation.
Improve to 85% satisfaction with the timeliness and accuracy of claims payment.
Improve to 85% satisfaction with the number of sessions authorized.
Improve to 85% satisfaction with the time it takes APS-PR to notify practitioners
of their network status.
C. Routine Monitors
On at least a quarterly basis data are compiled and reviewed by the APS PR Quality
Improvement Committee for the following routine monitors:
•
•
•
•
•
•
•
•
Utilization management statistics
Credentialing performance indicators
Member and practitioner complaints processing
Appeals processing
Care management quality assurance audits
Customer service representative quality assurance audits
Telephone performance for member services and practitioner/provider
services
Claims processing
IV. Resources Dedicated to Quality Improvement
1. Human Resources Dedicated to Quality Improvement
Quality improvement is an ongoing and integrative process at APS-PR. APS-PR
provides quality improvement support and involvement at the corporate and health plan
division levels. This structure promotes an efficient use of resources and sharing of
ideas and data. Tables V.1.a, V.1.b and V.1.c illustrate resources APS-PR dedicates to
quality improvement activities.
Table IV.1.a: Quality Improvement Resources-Health Plan Division
APS-PR Position
Medical Director
Quality Improvement Director
President and Chief Executive Officer
Chief Clinical Officer
QI Supervisor
Data Analyst
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FTE Equivalent
.5
1.0
.25
.25
1.0
2.0
APS-PR Position
Client Services Specialist
TOTAL
FTE Equivalent
2.0
4
Table IV.1.b: APS-PR Corporate Quality Improvement Resources
APS-PR Position
FTE Equivalent
IS Staff
.25
Compliance Officer
.25
APS-PR Legal Counsel
.25
TOTAL
.75
2. Data and Information Systems Supporting Quality Improvement
APS-PR requires access to a wide range of data to carry out its quality improvement
activities. APS-PR also must manage the required data to support measurement and
evaluation of its quality improvement activities. Table V.2.a shows the data and
information systems that support quality improvement activities at APS-PR.
Table IV.2.a: Data and Information Systems Supporting Quality Improvement
System/Database
Data Source/Function
Paradigm
Utilization and Case Management System,
Claims Payment, Eligibility, Network
Information, Customer Service Logs.
Complaints Data Base
Complaint tracking and reporting.
Non-Cert/Appeals Logs
Denial and appeal tracking and reporting.
Quality of Care Issues
Tracks and reports individual quality of care
issues
Geo-Access Software
Reports on geographic availability of
practitioners and providers
V. Confidentiality
APS-PR Healthcare and its subsidiaries and affiliates are committed to ensuring that
privacy practices regarding individually identifiable health information comply with
industry best practices, covenants given to its clients (“ Covered Entities and Business
Associates”) and, as applicable, all federal and state laws and regulations including but
not limited to the Standards for Privacy of Individually Identifiable Health Information
promulgated pursuant to the Health Insurance Portability and Accountability Act
(“HIPAA”) (“the HIPAA Privacy Rule” or “the Privacy Rule”). Consequently, APS-PR is
committed to maintaining an administrative structure, reporting procedures, due
diligence procedures, training programs and other methodologies of an effective
compliance program relative to the use and disclosure of its customers’ protected health
information (“PHI”). The APS Chief Privacy Officer is responsible for development and
implementation of APS-PR’s confidentiality policies and procedures.
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VI. Evaluation and Update
An evaluation of the effectiveness of the APS-PR Behavioral Health QI Program is
prepared annually. Key components include:
•
•
•
•
Summary of quality assessment activities
Summary of quality improvement activities, projects and focus studies
Evaluation of the overall effectiveness of the quality improvement program
Progress toward improving safe clinical practices throughout the network
The evaluation is reviewed and approved by the APS-PR QIC. The evaluation is
forwarded to the APS Corporate Quality Improvement Committee (CQIC) for review and
final approval.
The APS-PR Behavioral Health Quality Improvement Program Description is reviewed
and updated annually. The updated APS-PR Behavioral Health Quality Improvement
Program Description is approved by the APS-PR QIC. Following approval by the APSPR QIC, the program description is forwarded to the APS CQIC for review and final
approval. Required reviews and approvals are reflected in the minutes of each of the
appropriate committees.
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