1 Provider Manual March 2013
Provider Manual March 2013 Leadership, Partnership, Excellence 1 Table of Contents Introduction and Overview .........................................................................................................8 Message from the Area Director ..............................................................................................8 Welcome to CoastalCare .........................................................................................................9 Who we are: ..........................................................................................................................10 Description of Expectations/Collaboration Goals ...............................................................10 Mission Statement.................................................................................................................10 Vision Statement ...................................................................................................................11 Value Statement ....................................................................................................................11 The Medicaid Waiver: What is the NC DHHS Health Plan? .....................................................11 About the NC MH/DD/SAS Health Plan ..............................................................................12 About the NC Innovations Waiver ......................................................................................13 CoastalCare Governance and Administration ............................................................................13 Office of the CEO ...................................................................................................................14 Network Management Department.......................................................................................15 Utilization Management ........................................................................................................16 CM Functions .....................................................................................................................16 UR Functions ......................................................................................................................16 Routine Utilization Review .................................................................................................16 Focused Reviews ................................................................................................................17 Appeal Reviews ..................................................................................................................18 Quality Management .............................................................................................................18 Quality Assurance & Quality Improvement ............................................................................19 Corporate Compliance ...........................................................................................................19 Finance and Reimbursement .................................................................................................20 Care Coordination .................................................................................................................20 Customer Services/Call Center ...............................................................................................20 Medical Director ....................................................................................................................21 Operational Committees .......................................................................................................21 Provider Network ......................................................................................................................22 2 Description of Network..........................................................................................................22 Types of Providers ..............................................................................................................22 Quality of Care .......................................................................................................................25 Cultural Competency of the Network: ...................................................................................28 Definition of Cultural Competence ........................................................................................28 What changes should your program make to enhance cultural competence? ....................30 Cultural Competence Goal: ....................................................................................................31 Provider Communication .......................................................................................................31 Provider Council ....................................................................................................................33 Provider Enrollment and Credentialing ..................................................................................33 Performance Monitoring .......................................................................................................37 Gold Star Rating and Monitoring Process ...........................................................................37 Focused Monitoring ...........................................................................................................41 Quantitative Record Review ...............................................................................................41 Mystery Shopping ..............................................................................................................42 Changes in Qualification Status ..............................................................................................42 Applying for Additional Services .........................................................................................43 Implementation Review .....................................................................................................43 Network Development Plan ...................................................................................................44 Access & Availability Monitoring ............................................................................................45 Need/Gap Analysis ................................................................................................................46 CoastalCare Network Development Action Plan ....................................................................47 Contracts ...............................................................................................................................47 Minimum Criteria and Conditions to Participate in the Network ............................................50 Medicaid ............................................................................................................................50 State Funded Network .......................................................................................................50 Training .................................................................................................................................51 Technical Assistance ..............................................................................................................52 Consumer Rights and Empowerment ........................................................................................55 3 Rights of Consumers ..............................................................................................................55 Informed Consent ..................................................................................................................57 Psychiatric Advance Directives (PAD) .....................................................................................57 Confidentiality .......................................................................................................................59 Second Opinion .....................................................................................................................60 Reductions, Denials, Suspensions or Termination of Medicaid Services .................................61 Denial ................................................................................................................................61 Reductions, Suspension, or Termination ............................................................................61 Due Process for Medicaid Decisions ......................................................................................62 Appeal Level I .....................................................................................................................62 Steps to File an Appeal Request .............................................................................................62 Expedited Appeal Review Process ......................................................................................63 Mediation - Level II ............................................................................................................63 Appeal/Hearing - Level III ...................................................................................................64 Final Agency Decision - Level IV ..........................................................................................64 Non-Medicaid Service Appeal Process ...................................................................................65 Non-Medicaid Appeal Request to DHHS .............................................................................66 Receiving Services during the Non-Medicaid Appeal Process .............................................66 Consumer and Family Advisory Committee (CFAC) ................................................................66 Benefit Package.........................................................................................................................68 Eligibility ................................................................................................................................68 Who Is Eligible for the Medicaid Waivers? .............................................................................68 The NC Innovations Waiver (1915 c Waiver): .........................................................................69 Medicaid Waiver Dis-enrollment ...........................................................................................70 Eligibility for State Funded Services .......................................................................................70 Eligibility for Reimbursement by CoastalCare ........................................................................70 Enrollment of Consumers ......................................................................................................71 Service Definitions .................................................................................................................73 Service Array .........................................................................................................................73 4 Hospital Admissions...............................................................................................................73 Medicaid Transportation Services ..........................................................................................73 CoastalCare Clinical Design Plan ................................................................................................74 Access, Enrollment and Authorization of Services .....................................................................74 Accessing Routine Services ....................................................................................................74 Enrollment and Referral Process for Routine Needs ...........................................................74 Accessing Urgent Services......................................................................................................75 Enrollment and Referral Process for Urgent Needs ............................................................75 Accessing Emergent Services .................................................................................................77 Enrollment and Referral Process for Emergent Needs ........................................................78 Electronic Submission of Enrollments by Providers ................................................................80 Registry of Unmet Needs .......................................................................................................81 Care Coordination .....................................................................................................................82 Quality of Care .......................................................................................................................85 CCNC Collaboration ...............................................................................................................85 System of Care (SOC) .............................................................................................................86 System of Care Coordinators .................................................................................................86 Crisis Services ........................................................................................................................87 Innovations and Care Coordination........................................................................................87 Intellectual or other Developmental Disabilities (I/DD) ..........................................................89 Service Definitions and Criteria .................................................................................................90 Service Array .........................................................................................................................90 Medicaid Services ..............................................................................................................90 State Funded Benefit Plan ..................................................................................................91 Claims Information ....................................................................................................................92 Enrollment and Eligibility Process ..........................................................................................92 Eligibility Determination .....................................................................................................92 Enrollment Data .................................................................................................................92 Effective Date of Enrollment ..............................................................................................93 5 Patient ID ...........................................................................................................................93 Coordination of Benefits ........................................................................................................93 Eligibility Determination Process by Provider .....................................................................93 Obligation to Collect ..........................................................................................................94 Reporting of Third Party Payments.....................................................................................94 Process to Modify ..............................................................................................................94 Sliding Fee Schedules .........................................................................................................94 Authorizations Required for Payment ....................................................................................95 System Edits .......................................................................................................................95 Authorization Number & Effective Dates............................................................................95 Units of Service ..................................................................................................................95 Exceptions to Authorization Rule .......................................................................................95 Payment of Claims & Claims Inquiries ....................................................................................95 Clean Claims.......................................................................................................................95 Service Codes & Rates ........................................................................................................96 Standard Codes for Claims Submission ...............................................................................96 Timeframes for Submission of Claims .................................................................................96 NPI (National Provider Identifier) .......................................................................................97 Verification of Receipt of 837 Electronic Billing File ............................................................97 Provider Portal Direct Claims Submission ...........................................................................97 837 Claims Submission .......................................................................................................97 Process for Submission of Paper Claims .............................................................................98 Void and Replacement Claims Processing ..........................................................................98 Clearinghouse Claims Routing ............................................................................................98 Medicare Override Processing............................................................................................98 Claim Denial Inquiries ........................................................................................................98 Non –clinical claims appeals ...............................................................................................99 Response to Claims ................................................................................................................99 835 and Electronic Remittance Advice ...............................................................................99 6 Checkwrite Schedule and EFT Process ................................................................................99 Claims Investigations – Fraud & Abuse ..................................................................................99 Trends of Use & Potential Fraud.........................................................................................99 Audit Process .....................................................................................................................99 Voluntary Repayment of Claims ....................................................................................... 100 Reporting to State & Federal Authorities.......................................................................... 100 Repayment Process/Paybacks ............................................................................................. 100 Standards and Regulatory Compliance .................................................................................... 100 Introduction ........................................................................................................................ 100 Quality Improvement .......................................................................................................... 101 Provider Quality Management Plans ................................................................................ 101 Quality Improvement Projects ......................................................................................... 101 Performance Measurement ................................................................................................. 102 Data Collection and Verification ....................................................................................... 102 Performance Improvement .............................................................................................. 102 Provider Performance Profile ........................................................................................... 102 North Carolina Support Needs Assessment Profile-NC SNAP ............................................ 103 North Carolina Treatment and Outcomes Program Performance System –NC TOPPS....... 106 Performance Monitoring ..................................................................................................... 106 Monitoring of Incidents .................................................................................................... 107 Incident Reporting ........................................................................................................... 108 Additional Reporting to the MCO and DMH/DD/SAS: ....................................................... 109 Restrictive Interventions: ................................................................................................. 109 Where to report incidents: ............................................................................................... 110 Incident Review Process ................................................................................................... 110 Grievances ....................................................................................................................... 111 Perception of Care Surveys .............................................................................................. 112 Medical Record Requirements/Service Record Standards .................................................... 113 State Level Requirements Documents .............................................................................. 113 7 Federal Level Requirements Documents .......................................................................... 114 Corporate Compliance ............................................................................................................ 114 Corporate Compliance Program........................................................................................... 114 Corporate Compliance Plan .............................................................................................. 115 Compliance Committee .................................................................................................... 115 ComplianceHelp Desk ...................................................................................................... 116 Compliance Reporting Tools ............................................................................................. 116 Monitoring and Auditing .................................................................................................. 116 Investigation and Reporting ............................................................................................. 116 Code of Ethics ...................................................................................................................... 116 False Claims Act Education Requirements& Affordable Care Act ......................................... 117 Dispute Resolution Process for Providers ................................................................................ 117 Glossary of Terms.................................................................................................................... 123 Appendices ............................................................................................................................. 143 Official Communication Memos .............................................................................................. 144 Code of Ethics Policy ............................................................................................................... 145 Federal State and Local Requirements .................................................................................... 147 Introduction and Overview Message from the Area Director Welcome to the CoastalCare Network! Together, we will develop a comprehensive system of care for those in our community having a mental illness, an intellectual/developmental disability or a substance use issue. Our goal is to offer a system that is accessible, responsive and of the highest quality; all while keep cost reasonable to the taxpayer. We promise to assist you in overcoming barriers to effectively operate within the CoastalCare network. We also promise to hold you accountable, as we hold ourselves, to the contract 8 requirements to provide high quality services, and for improving the quality of life for those we serve. Your membership in the CoastalCare network is regarded as a commitment to partner with us and others to achieve the goals of the Medicaid Waiver; improve quality of care, improve access to services and promote cost efficiencies. Together we can meet the needs of the present with an eye to the future. Good luck and congratulations on becoming a part of the CoastalCare network. Sincerely, Foster Norman Area Director/CEO CoastalCare Welcome to CoastalCare Welcome to the CoastalCare network of providers! As part of this network, you join a group of colleagues committed to providing the highest quality of care that meets the needs of citizens residing in Brunswick, Carteret, New Hanover, Onslow and Pender counties. Thank you for joining CoastalCare’s mission to improve the quality of life of individuals who have a mental illness, substance use disorder or intellectual and other developmental disabilities. The CoastalCare Provider Manual is the most comprehensive source of instructional information available from CoastalCare to providers. It is intended as a detailed reference to assist providers in following policies and procedures for CoastalCare. It also details statewide procedures and regulatory information. It is your responsibility to be familiar with the information provided in this manual, as well as to adhere to the policies and procedures outlined. Compliance with this manual is necessary to fulfill contractual obligations as a service provider with CoastalCare. Your knowledge and practice of this manual will also assist CoastalCare in providing you with timely service authorizations and claims reimbursement. CoastalCare is available to answer questions and offer technical assistance Monday through Friday, 8 a.m. to 5p.m. Please call our Customer Services line at 1-855-250-1539. 9 Thank you for participating in the CoastalCare network and for your dedication to those that both providers and CoastalCare serve. We look forward to our partnership in serving our community. Who we are: CoastalCare is a local political subdivision of state government established under North Carolina General Statute 122-C, and has been selected as aMedicaid 1915 (b) (c) Waiver site beginning January 1, 2013. CoastalCare is the result of a merger between two area authorities, Onslow Carteret Behavioral Healthcare Services and Southeastern Center for Mental Health, Developmental Disabilities and Substance Abuse Services. CoastalCare manages a network of providers that serve individuals with mental health, intellectual/developmental disabilities, and substance use disorders that reside in Brunswick, Carteret, New Hanover, Onslow, and Pender Counties. CoastalCare is nationally accredited by URAC in four functional areas: Claims Processing, Health Call Center, Health Network Management, and Health Utilization Management. CoastalCare manages state allocated dollars, federal block grants awarded by the State of North Carolina, and is one of 11 Medicaid 1915 (b) (c) Waiver sites in North Carolina that manage the Medicaid funded services through a capitated Pre-paid Inpatient Health Plan (PIHP) beginning January 1, 2013. Description of Expectations/Collaboration Goals A self-managed system relies on educated providers who understand and operate intandem with CoastalCare Clinical Objectives and the Clinical Design Plan. Our goal is todevelop a system where the structure, requirements and expectations are so well known,that extensive management and intervention by CoastalCare is not required. This model includesthe engagement of our Providers in the management of the system and relies on theirinvolvement in the development of strategies to meet quality and performance goals anddevelop solutions for systemic problems. Providers participate with CoastalCare through the CoastalCare Provider Council and the Clinical Advisory. Provider participation in the ongoing operations of the CoastalCare system is critical in the efficient and effective identification of strategies that willensure success in achieving our goals. Our joint purpose is to assure easy access,appropriate,high quality services for consumers, and the elimination of ineffective andpoor outcome services and practices. Mission Statement 10 To improve the quality of life of individuals who have mental illness, substance use disorders and intellectual and other developmental disabilities through efficient management of an effective care system in our communities. Vision Statement To be recognized as a national leader in Public Managed Healthcare. Value Statement CoastalCare effectively manages its resources in a fair and equitable manner with efficiency, accountability, and integrity for the needs of the present, with an eye to the future. CoastalCare will promote services which are: Innovative Accessible Responsive Inclusive Culturally Sensitive Respectful Evidence Based The Medicaid Waiver: What is the NC DHHS Health Plan? The NC DHHS approved 1915(b)(c) Waiver is a Pre-paid Inpatient Health Plan (PIHP) funded by Medicaid. All Medicaid MH/DD/SA services are authorized by and provided through the CoastalCare Provider Network in accordance with the risk contract between the Division of Medical Assistance/Department of Health and Human Services and CoastalCare. As a prepaid inpatient health plan, CoastalCare is at financial risk for a discrete set of MH/DD/SA services, including both NC Medicaid State Plan services and services included in the NC Innovations waiver. The NC MH/DD/SAS Health Plan is a combination of two types of waivers: a 1915(b) waiver generally known as a Managed Care/Freedom of Choice Waiver, and a 1915(c) waiver generally known as a Home and Community Based Waiver. Through the 1915(b) section of the Social Security Act, States are permitted to submit a request to waive some Medicaid requirements in order to provide alternatives to the traditional fee for service system of care. Likewise, through 11 the 1915 (c) section of the Social Security Act, States are permitted to submit a request to waive some Medicaid requirements in order to provide alternatives to institutional care. Both waivers are approved under different Federal Medicaid Regulations and require different reporting and oversight. This type of waiver system is not intended to limit care or choice but to create an opportunity to work closely with consumers and providers on better coordination and management of services, resulting in better outcomes for consumers and more efficient use of resources. Opportunities that a 1915(b)(c) waiver system presents: In order to encourage: Coordination - The waiver allows for better coordination of a system of care for consumers, families and providers. Efficient Management of limited public resources - We are able to manage all system resources so that money can be directed to services most appropriate for identified consumer needs. Flexibility in services offered - We have developed a more complete range of services and supports through Medicaid B-3 authority in order to reduce and redirect reliance on high cost institutional and hospital care. About the NC MH/DD/SAS Health Plan This waiver applies to consumers with Medicaid that reside in any of our counties: Brunswick, Carteret, New Hanover, Onslow, and Pender. All Medicaid Clients enrolled in specified eligibility groups will automatically be enrolled into this plan for their mental health, developmental disability, and substance abuse service needs. The services that are available will include current NC State Mental Health Plan Medicaid services including Inpatient Psychiatric care and Intermediate Care Facilities for the Mentally Retarded (ICF/MR). CoastalCare has partnered with the state to create additional services that have been identified as best practices in care, B(3) services. Under Medicaid B(3) authority, funds that are typically used to serve a person with intellectual/developmental disabilities in an Intermediate Care Facility for the Mentally Retarded (ICF-MR), through this waiver can be used to “follow the person” to services outside of the ICF-MR facility.The CoastalCare Provider Network is qualified to provide best practice services.Consumers will be able to choose from any provider in CoastalCare’s network that is contracted and accessible to provide the service they need.Information and education will be 12 provided to consumers to help them choose providers.Access to care is made easier through CoastalCare’s Call Center (1-866-875-1757) About the NC Innovations Waiver The NC Innovations waiver is a Home and Community Based Waiver 1915 (c). This is a waiver of institutional care.This waiver incorporates the essential elements of Self-Direction, Person Centered Planning, Individual Budgets, Participant Protections and Quality Assurance. The waiver supports the development of a stronger continuum of services that enable individuals to move to more integrated settings. People served and their families have the information and opportunity to make informed decisions about their health care and services, and exercise more control over the decisions they make regarding services and supports. The NC Innovations Waiver has both a Provider Directed and Individual/Family Directed track. In the Provider Directed track, the services are delivered in a traditional manner with consumers and family members selecting the providers they believe can best meet their needs. Participants and their families may choose from two models of Individual /Family Directed services, Employer of Record or Agency with Choice. In the Employer of Record Model, the staff are hired, directed and paid by the NC Innovations participant/legally responsible persons with the assistance of a Community Guide and a Financial Supports Agency. In the Agency with Choice model, the provider agency is the legal employer but the participant/legally responsible person is the Managing Employer. The managing employer is responsible for interviewing, training, managing (with oversight by the agency Qualified Professional) making recommendations to the provider agency for hiring and firing. A consumer or guardian/family member can choose Provider Directed, Individual /Family directed or a combination of both options. CoastalCare Governance and Administration CoastalCare is a local political subdivision of state government established under North Carolina General Statute 122-C. The CoastalCare Area Board is a governing body, focused on establishing and monitoring the goals and objectives of the agency, as well as the development of public policy. The Chief Executive Officer (CEO) reports to the Area Board, and all other staff of CoastalCare reports to the CEO. CoastalCare is nationally accredited by URAC in four functional areas: Claims Processing, Health Call Center, Health Network Management, and Health Utilization Management. CoastalCare manages state allocated dollars, and federal block grants awarded by the State of North Carolina, and is one of 11 Medicaid 1915 (b) (c) Waiver sites in North Carolina. As a Medicaid 13 Waiver site, CoastalCare manages the Medicaid funded services through a capitated Pre-paid Inpatient Health Plan (PIHP). Office of the CEO The Office of the CEO is responsible for the overall management of administrative and clinical operations for CoastalCare, as well as performance outcomes and achievement of goals. The Office of the CEO consists of The Chief Executive Officer, Chief Operating Officer, Chief Medical Director, Medicaid Waiver Project Coordinator, Public Information Officer and Executive Assistant and Clerk to the Area Board. This unit maintains strong relationships with local and state partners including provider agencies, public agencies, public and elected officials and advocacy groups. The Office of the CEO charges the Executive Team with supporting CoastalCare staff in achieving the goals and objectives of the agency. CoastalCare is organized into several functional departments shown below. These departments have been established to perform operational functions that support the mission of CoastalCare. Area Board Office of the CEO Executive Assistant and Clerk to the Board Chief Operating Officer Medicaid Waiver Project Coordinator Public Information Officers Chief Operating Officer Community Development Care Coordination Customer Services CoastalCare Jacksonville Office Corporate Compliance Public Information Officer CoastalCare Corporate Headquarters Wilmington, NC CFAC Functional Departments: Finance Human Resources Information Technology Customer Services Community Development Care Coordination Corporate Compliance Network Management Quality Management Utilization Management CoastalCare Morehead City Office Network Management Care Coordination Customer Services Finance 14 Network Management Department Mission Statement The Network Management Department shall contract with, monitor and support providers of behavioral health and developmental disability services to ensure a high quality network sufficient to meet the prioritized needs of the eligible population. Network Management Purpose It is the purpose of the Network Management Department to maintain and manage a provider network with the capacity and competence to effectively meet the assessed service needs of the culturally diverse population within the agency’s catchment area. It is also the purpose of the Network Management Department to implement a comprehensive provider relations program that includes established mechanisms for assisting providers regarding network issues, securing provider suggestions and guidance in improving services delivered to consumers, soliciting provider participation in the review of agency network management design, function and activities, and mechanisms for ongoing communication with providers including the provider manual and communication plan. The department performs essential functions of provider contracting, enrollment, endorsement, monitoring, application of violations, implementation of corrective actions and/or sanctions, and network performance assessment, tracking and reporting. Network Management Department Organization The Network Management Department has staff organized in a manner to address both system-wide goals, processes and to be responsive to the needs of individual providers. The Department Director directly oversees the development staff, including the Network Development Coordinators, Contract Administrator and Credentialing staff. These positions assist with network development planning, sufficiency assessment, implementing a qualified network of providers and reporting. The department Liaison Supervisor, who reports to the NM Director, oversees the Liaisons who assist with network management and monitoring activities. The Liaisons are assigned to specific providers to establish effective and knowledgeable collaboration as they address provider-specific endorsement, monitoring, technical assistance and support. Communication is directed at system-wide, disability-specific and individual provider levels. 15 Utilization Management The Utilization Management (UM) Department includes Care Management (CM) and Utilization Review (UR) functions. CM Functions The Care Managers determine whether a consumer meets and continues to meet medical necessity criteria and target population requirements for the frequency, intensity and duration of requested services. Our goal is to ensure that consumers receive the right service, at the right time, and at the right level of care creating the most effective and efficient treatment possible. This work is accomplished through consistent and uniform application of CoastalCare’s Clinical Decision Support Tools for each consumer’s individual clinical needs to determine the appropriate type of care, service, frequency of services, and intensity of services, in the appropriate clinical setting. UM Care Managers assist the provider in managing a consumer’s care needs and identification of appropriate services. UR Functions The primary Utilization Review function is to monitor the utilization of mental health, substance use and intellectual/developmental disability services and review utilization data to evaluate and ensure that services are being provided appropriately within established benchmarks and clinical guidelines; that services are consistent with the authorization and approved Person-Centered Plan (PCP)/Treatment Plan. Our goal is to ensure that consumers receive the right service; at the right time; at the right level; creating the most effective and efficient treatment possible. Utilization review is a post-service review process that involves a pulling a sample from paid claims. Information from the consumer’s record (assessment information, treatment plan and progress notes) is evaluated against Medical Necessity Criteria. Indicators will be identified to select cases for review, such as high utilization of service, frequent hospital admissions, etc. as well as random sampling of other events. CoastalCare uses both Focused Utilization Review and a sampling process across Network Providers in its Utilization Review methodologies. Routine Utilization Review 16 Routine Utilization Review will focus on the efficacy of the clinical processes in cases as they relate to reaching the goals in the consumer’s PCP / treatment plan. CoastalCare will also review the appropriateness and accuracy of the service provision in relation to the authorizations. All providers contracted with CoastalCare who are currently serving CoastalCare consumers are subject to Utilization Reviews to ensure that clinical standards of care and medical necessity are being met. A routine UR will be inclusive of, but not limited to: evaluations of services across the delivery spectrum; evaluations of consumers by diagnostic category or complexity level; evaluations of providers by capacity, service delivery, and bestpractice guidelines and evaluations of utilization trends. The criteria used in the Utilization Review processes will be based on the most current approved guidelines and service manuals utilized under the NC MH/DD/SAS 1915b and c waivers and processes for NC State services. These documents include, but are not limited to, the current NC State Plan service definitions with Admission, Continuation, and Discharge criteria; the CoastalCare approved Clinical Guidelines; the current approved NC DMA Clinical Coverage policies. Focused Reviews A Focused Review will be based on the results of Monitoring Reports that identify outliers as compared to expected / established service levels or through specific cases identified in the CoastalCare clinical staffing process to be outside the norm. Focused samples may include: High-risk consumers - Examples may include, but are not limited to, consumers who have been hospitalized more than one time in a 30-day period; developmentally disabled consumers as identified in the Risk/Support Needs Assessment; children and youth with multiple agency involvement; or active substance use by a pregnant female. Under-utilization of services – Examples may include, but are not limited to, consumers who utilize less than 70% of an authorized service or consumers who have multiple failed appointments. Over-utilization of services – Example: consumers who continue to access crisis services with no engagement in other services. Services infrequently utilized – Example: an available practice that is not being used. High-Cost Treatment – Consumers in the top 10% of claims for a particular service 17 Appeal Reviews An Appeal Review is a local impartial review of CoastalCare’s decision to reduce, suspend, terminate or deny Medicaid services. A health care professional who has appropriate clinical expertise in treating the Consumer’s condition or disorder, and who was not previously involved in CoastalCare’s initial decision, determines the Appeal Decision. (See Reductions, Denials, Suspensions or Terminations of Medicaid Services for more information) Your responsibility as a CoastalCare Contracted Provider is to: Submit Service Authorization Requests (SAR) with the proper clinical information to allow UM Care Managers to review for medical necessity; and Submit Continuing Service Authorization Requests on a timely basis to allow for Utilization Management activities and authorization prior to beginning services. Emergency Authorizations are available, but should only be used when necessary to provide for consumer health and safety. CoastalCare’s responsibility to Providers is to: Provide accurate and timely response to Service Authorization Requests and to ensure that consumers receive services for which they are eligible, and which are clinically appropriate. Quality Management CoastalCare maintains a Quality Management Program which is a comprehensive, proactive program that provides the structure, process, resources, and expertise necessary to systematically define, evaluate, monitor and ensure that high-quality, cost-effective care and service are provided to members. The program is a commitment to continuous quality improvement principles and requires participation of the Area Board, providers, and staff members. The Quality Management Program includes a continuous, objective, and systematic process for: monitoring and evaluation of key indicators of care and service; identification of opportunities for improvement; development and implementation of interventions to address the identified opportunities; and for re-measurement to demonstrate effectiveness of program interventions. 18 Quality Assurance & Quality Improvement Quality Improvement goes beyond Quality Assurance. Perhaps the defining difference lies in the fact that in addition to focusing on processes, correcting problems, analyzing data, and making decisions based on information, QI emphasizes “Improvement”, not mere “Compliance.” This is a distinct difference that focuses on going beyond standards and regulations to a passion that believes that improvement is possible and preferable rather than maintaining the status quo. In North Carolina, this has been a significant paradigm shift for health care and for mental health, substance abuse, and developmental disabilities services in particular. However, Quality Assurance (QA) is much needed set of activities to ensure compliance with rules, regulations, and requirements. It provides the basic foundation for a quality improvement model and methodology. Quality Improvement (QI) is a planned, systematic, organization-wide approach for monitoring, analyzing, and improving organizational and provider performance. QI promotes the ongoing participation of all staff, consumers, providers, family members, and other stakeholders in problem-solving efforts across functional and hierarchal boundaries. Adding the two elements together produces a comprehensive approach to assuring quality care: Quality Management; QA + QI = QM. Corporate Compliance The purpose of CoastalCare’sCorporate Compliance department is to maintain an effective best practice compliance program. The department conducts activities to prevent, detect and correct fraud, waste and abuse to ensure the financial and clinical integrity of the agency. The department conducts post-payment audits, monitoring and investigations to assure that payment made to providers for services are rendered in accordance with rules, regulations, policies and the terms of the provider contract. The departmentreceives allegations of fraud and abuse from various sources to include, tip-line, complaints, incidents, issues identified by staff, data mining, detection tools and statistical sampling. The department conducts reviews of all allegations and if warranted conducts an investigation. The department makes referrals of suspected fraud and abuse to Division of Medical Assistance-Program Integrity and other appropriate regulatory bodies. The department maintains the Corporate Compliance Plan.The department develops and facilitates education and training on prevention, detection and reporting of fraud, waste and abuse for staff, providers and stakeholders. 19 Finance and Reimbursement The primary purpose of the Business Management Department is the organization of the fiscal and budgetary operations of the Area Authority. The department is responsible for sound financial planning for the area program and for ensuring compliance with all fiscal policies at the local, state and federal levels. The Business Management department comprises the following areas: general budget and finance, claims processing and physical plant operations and maintenance. Care Coordination Care Coordination will ensure each consumer identified as having special health care needs receives a course of treatment, with regular care monitoring that addresses their individualized needs. Mechanisms used to ensure appropriate treatment planning include; engagement of the appropriate treatment providers in the Person Centered planning process, review by community high risk team inclusive of CCNC and primary care providers, referral to appropriate professionals for additional assessment as needed. The care coordinator will ensure the development of a treatment plan that meets these conditions. Customer Services/Call Center CoastalCare is responsible for publishing two toll free numbers, one to access the Customer Service Office (1-855-250-1539) and the other to access the Call Center (1-866-875-1757). The Customer Service Office is staffed with Qualified Professionals whose primary purpose is to assist consumers, their family members, providers, and other stakeholders to resolve routine complaints and ensure that accurate and relative information surrounding the MCO, network of providers, and service availability is accessible. As outlined in the CoastalCare organizational structure, the office of Customer Service is clearly defined as a separate division with clear functions from Utilization Review, Finance, Planning and Collaboration, Quality Management and Network Management to ensure fair and impartial review of issues and actions. Customer Service Representatives are available by calling the toll-free Customer Services line listed above or by emailing [email protected]. Customer Service Representatives are available Monday-Friday, 8 a.m. to 5 p.m. 20 CoastalCare is also responsible for ensuring a timely response for consumers accessing mental health, intellectual/developmental disabilities, and substance abuse services. The Call Center line is available 24 hours per day, 7 days per week, 365 days per year. It is staffed with licensed clinicians whose primary purpose is to assess consumers’ needs and offer options based on the consumers’ preferences and the service needed. Call Center Clinicians also monitor follow-up to care to ensure consumers have initiated services. Once the consumer has chosen a provider, Call Center Clinicians will schedule an appointment with that provider through the provider’s AlphaMCS calendar. Medical Director CoastalCare’s Medical Director is the Chief Medical Officer and is responsible for overall clinical operations at the corporate office. The CoastalCare Medical Director is responsible for the overall clinical management of services to consumers, including authorization of services, quality oversight, and utilization management. Other activities include collaboration with CoastalCare’s network providers, primary care providers in the community, and State and community hospitals as well as development of preventive health projects for CoastalCare’s consumers. Operational Committees The committee structure of CoastalCare has been revised to include six committees that revolve around the functions of the organization as a MCO: Quality Management Committee, Network Development and Management Committee, Utilization Management Committee, Community Coordination Committee, Claims Processing Committee, and Customer Services/Call Center Committee. Each committee has oversight for the operations of a particular function and each department has a designated committee to review its particular functions. These committees are referred to as content committees. If needed, each committee can also develop sub-committees for particular areas of interest or projects. There are additionally two subcommittees of the Quality Management Committee: Corporate Compliance and Training. The Network Management Committee has a subcommittee as well known as the Clinical Advisory Committee. This committee serves as an advisory group whose membership includes various stakeholders (e.g. providers, licensed independent practitioners, CCNC, DSS, etc.). This sub-committee serves as a formal mechanism for soliciting stakeholder input regarding clinical processes, work products, etc. for the organization. All committees report their activities to the Quality Management (QM) Committee. 21 Each committee is responsible for the review of data relative to the functional areas of the organization. Data identified as outliers within each committee is then reported to the Quality Management Committee for further analysis and the identification of an action plan. The established committee structure serves as a formal mechanism for communication and feedback loops, including data reporting throughout the organization. Provider Network Description of Network CoastalCare is an oversight agency that has written agreements (contracts) with a specialty network of participating providers to provide outpatient/periodic services, enhanced benefit services, residential services, and crisis services. These services are available in a variety of settings including offices, the consumers’ homes, the general community, and in licensed facilities. CoastalCare is responsible for a five county area in North Carolina. The five counties are; Brunswick, Carteret, New Hanover, Onslow and Pender. Types of Providers Periodic services can be office based or community based. Examples of these services include direct DD services such as personal assistance, respite and Adult Day Vocational Programs. Providers of these services have office locations in all five (5) counties and the community based services are available in all five (5) counties. Enhanced benefit services can be community based (such as Community Support Team) or based in a Division of Health Service Regulation (DHSR) licensed facility (such as SAIOP, Psychosocial Rehabilitation). Providers of enhanced benefit services serve all five counties and facilitate transportation to facilities when necessary. CoastalCare has identified two enhanced benefit services for priority monitoring because they are high cost and delivered to priority consumer populations. These are Assertive Community Treatment Teams (ACTT) and Substance Abuse Intensive Outpatient (SAIOP) treatment. ACTT is an evidence based practice to meet the identified needs of recipients who have serious and persistent mental illness and/or cooccurring disorders and the most complex treatment needs. This is a community based service available to consumers throughout the catchment area. SAIOP is provided in a licensed facility and is the identified best practice for adult substance abuse consumers according to the ASAM level of care criteria. 22 Residential services are provided in licensed facilities. There are local group homes & child residential beds, as well as agreements with out-of-area providers for specialty beds or local capacity limitations. CoastalCare is able to enter into temporary contractual arrangements, with providers outside of the geographic area, so that the goals of access can be met for all consumers who are legal residents of the geographic area. Clinical Home for Consumers The state Medicaid Service definitions implemented in March 2006 included the designation of a Clinical Home for consumers. The role of the Clinical Home is further reinforced by the development of the Critical Access Behavioral Health Agency model (CABHA). CABHAs are designed to provide the core clinical services that are needed to ensure consumers receive the continuity of services that they need. Expected Outcomes for CABHAs and other providers functioning as Clinical Home Providers: 1. Single point of responsibility to plan, link and coordinate clinical and support services for consumers. 2. Clinical accountability. 3. First Responder responsibility is clearly assigned. 4. Responsible for development of Crisis Plan or Advance Directive 5. Team approach to planning and monitoring care. Team includes (as appropriate) psychiatrist, nurse, licensed professional, and peer specialist as well as staff from other provider agencies serving the person. 6. Development of Person Centered Plans that reflect all consumer needs. 7. Communication with primary healthcare provider. First Responder Many of the Medicaid State Plan service definitions approved in 2006 and revised in 2010 include a “first responder” requirement as part of the service definition. This requires that providers have on-call capacity to respond in the case of a crisis for a consumer that is in their care. This means that consumers will have the advantage of having someone that knows them respond when they experience a crisis Crisis Services for mental health and substance abuse detoxification issues are available through a local Facility Based Crisis (FBC) provider, a Mobile Crisis Management team and WalkIn Crisis Clinic in multiple locations. Licensed Practitioners and Professional Practice Groups are Medical Doctors (M.D.), Practicing Psychologists (Ph.D), Psychologist Associates (Master’s Level Psychologist [LPA]), Master’s Level Social Workers (LCSW), Licensed Marriage and Family 23 Therapists (LMFT), Licensed Professional Counselors (LPC), Licensed Clinical Addiction Specialists (LCAS), Advanced Practice Psychiatric Clinical Nurse Specialists, Psychiatric Nurse Practitioners, and Licensed Physician Assistants who are members of the Provider Network and bill under their own license. Licensed Practitioners must be credentialed by CoastalCare. Our enrollment process includes background checks, reference checks, license verification and other evaluation criteria to make certain the provider meets CoastalCare and URAC criteria. Additionally CoastalCare collects information about specific expertise of Licensed Practitioners (such as Women’s issues, Trauma experience, etc.) in order to help consumers make choices about providers. Provisionally Licensed Practitioners are practitioners who are provisionally licensed in NC and are employed by a Network Provider Agency, Hospital, or Group Practice. Provisionally Licensed Practitioners may serve Medicaid consumers if they are working for an agency, hospital, or group practice that is fully contracted with CoastalCare to provide Outpatient Treatment. Under these circumstances a Provisionally Licensed Practitioner may submit a CoastalCare Application To Participate as a HealthCare Practitioner. In addition to completing and submitting the application, the Provisionally Licensed Practitioner must also provide proof of professional clinical supervision as evidenced by a current supervision contract including the name and contact information of the clinical supervisor. The clinical supervisor must provide an attestation stating that the provisionally licensed practitioner is receiving supervision and that the supervisor has approved the supervision contract. Upon approval by the Credentialing Committee, the Provisionally Licensed Practitioner will be able to provide Outpatient Treatment to CoastalCare consumers and submit claims for those services in accordance with the CoastalCare Provider Contract, the practitioners Licensing body, and/or limitation established by CoastalCare’s Credentialing Committee. Out of Area Provider is a contracted Agency or Licensed Independent Practitioner, which provides specialty services that are not available within the CoastalCare catchment area. Such providers meet all network requirements and are considered to be full members of the CoastalCare Network. Non-Enrolled, Non-Contracted Providers: If a CoastalCare consumer requests services from a provider who does not wish to apply to become a contracted provider with CoastalCare or is unable to pass the Enrollment process, the licensed independent practitioner or agency will be required to transition the consumer to the CoastalCare contracted provider of their choice within 60 days. 24 If a person receives non-emergency services from a non-enrolled, non-contracted provider, CoastalCare will not pay for the service. CoastalCare will pay for acute behavioral emergency care for a CoastalCare Consumer by a non-enrolled, non-contracted provider. When a consumer enrolled in the NC MH/DD/SA Health Plan resides outside of the CoastalCare counties, CoastalCare will work collaboratively with the consumer and providers in that area to ensure that the consumer has access to needed services. Most services will be available within thirty (30) miles or thirty (30) minutes. However, some specialty providers may be located outside the person’s county of residence. There may be only one provider of facility based services, such as Psycho-social Rehabilitation in a county due to insufficient demand to support two providers and economy of scale factors. CoastalCare annually evaluates the location of providers and types of services in its Sufficiency Analysis, and determines the need for additional providers. CoastalCare also maintains geo-maps which allow us to evaluate location of providers in relation to where consumers live within the catchment area. Quality of Care CoastalCare’s responsibility is to assure the quality of services provided by the CoastalCare Network of Providers. CoastalCare is accountable to the Division of MH/DD/SA and the Division of Medical Assistance in the management of both state funded and Medicaid services. In addition to state requirements, Medicaid waiver quality requirements are extensive and include: Health and safety of consumers Rights protection Provider qualifications Consumer satisfaction Management of complaints Incident investigation and monitoring Assessment of outcomes to determine efficacy of care Management of care of Special Needs Populations Preventive health care initiatives Clinical best practice Coastal Care has numerous quality, satisfaction and financial reporting requirements related to our agreements with the Division of MH/DD/SA and DMA. An Intra-Departmental Monitoring Team evaluates CoastalCare’s performance annually. CoastalCare understands the important role of quality management in protecting consumers and in promoting quality of care. 25 Your responsibilities as a CoastalCare Provider: Ensure that consumers meet medical necessity requirements for all services that you or your agency provides. Provide medically necessary covered services to consumers according to your contract and as authorized by CoastalCare. Strive to achieve best practice in every area of service. Provide culturally competent services and ensure the cultural sensitivity of staff members. Develop a Cultural Competency Plan and comply with cultural competency requirements. Have a clinical backup system in place to respond to crisis/emergencies for consumers receiving services. Part of this clinical function is to develop crisis plans that are available to clinicians in your office for consumers, their natural supports and CoastalCare. The clinical backup system will provide information and directions on how to seek assistance in a crisis/emergency including coverage for posted office hours, week-ends, and holidays for all consumers you serve or to serve as first responder as outlined in the service definition of your contract. Demonstrate consumer friendly services and attitudes. The Network Provider must have a system to ensure good communication with consumers and families. Comply with the policies and procedures outlined in this manual, any applicable supplements, CoastalCare Communication Memos and in the Provider Contract, including the General Conditions of the Contract and applicable state and federal laws and regulations. Provide services in accordance with all the applicable state and federal laws and regulations. Provide services in accordance with access standards and appointment wait time as noted in the General Conditions of the Provider Contract. Have a no reject policy for consumers who have been determined to meet medical necessity for the covered services by the provider or by the Licensed Independent Practitioner. CoastalCare Providers must provide their consumers with 24/7/365 telephonic access to a clinician or qualified professional in the case of an MH/DD/SA crisis or emergency. This contact may not be 911. This contact may also not be a hospital or mobile crisis team unless that is the service being provided under contract with CoastalCare. The contact person must: o Have the qualification, training and capacity to navigate the range of MH/DD/SA crisis scenarios a consumer may experience; o Advise the consumer and assist in the coordination of care during the crisis; 26 o Be available telephonically and may assist in-person if the situation requires; o Have immediate access to crisis plans for consumers who have crisis plans; o CABHA’s and other enhanced service providers must also ensure they fully comply with additional first responder duties outlined in state policies and service definitions. Work with CoastalCare to ensure a smooth transition for any consumers that desire to change providers, or when you need to discharge a consumer because you cannot meet his/her special needs. Document all services provided as per Medical Requirements, NC Waiver requirements and North Carolina State Rules. Agree to cooperate and participate with all utilization review/management, quality management, other reviews, and appeal and grievance procedures. Comply with Credentialing and Endorsement Procedures of CoastalCare that are outlined in the Enrollment Process to become a Network Provider. Comply with Authorization and Utilization Management requirements of CoastalCare. Comply with re-credentialing or re-qualifying procedures of Coastal Care. Participate in consumer satisfaction surveys, provider satisfaction surveys, clinical studies, incident reporting, and outcome requirements. Establish a plan and process for maintenance of personnel and consumer medical records in accordance with the Records Management and Documentation Manual (APSM 45-2) records retention schedule CoastalCare’s Responsibilities to Providers: Provide assistance twenty-four (24) hours a day, seven (7) days a week to consumers, and potential consumers including crisis coordination. Assist providers in understanding and complying with CoastalCare policies and procedures, applicable policies and procedures of the Department of Health and Human Services and federal agencies including Centers of Medicare and Medicaid, as well as the requirements of our accreditation agencies including, but not limited to the Utilization Review Accreditation Commission (URAC). Provide technical assistance related to CoastalCare’s contract requirements, CoastalCare’s Provider Manual requirements, DMA and DMH/DD/SAS requirements of providers, the development of appropriate clinical services, quality improvement initiatives, or to assist the provider in locating sources of technical assistance. CoastalCare is not required to provide technical assistance in areas that would normally be considered standard operational activities of a provider agency or to providers that have shown by history not to be able to assimilate previous technical assistance. 27 Make available to providers upon request, the results of its Sufficiency Assessment which identifies providers that are under or over capacity as well as priorities for Network Development. CoastalCare is not required to contract with providers beyond the number necessary to meet the needs of its Consumers. As a part of the continuous quality improvement process, CoastalCare has a Quality Management Committee (QMC). The Quality Management Director develops the Quality Improvement Plan that is reviewed and approved annually by QMC and the Area Board. The Plan identifies strategies and approaches that are designed and implemented to identify, track and trend CoastalCare and system wide performance of outcomes, structures and processes designed by the Area Board, CoastalCare, DHHS, federal and state guidelines and accreditation standards. The strategies and approaches shall include performance measures related to access to services, complaints, satisfaction and others reflective of the scope of URAC accredited programs. CoastalCare makes information available about it QMC performance to providers, practitioners, members and stakeholders . Cultural Competency of the Network: It is important that the CoastalCare Provider Network is able to adequately meet the needs of people from all ethnic groups. CoastalCare’s comprehensive process for gathering and analyzing information identifies needs and gaps in service capacity in the five county geographic catchment area. This is one mechanism to assess network adequacy and sufficiency. From this needs and gaps assessment, CoastalCare develops mechanisms to measure and address the culturally sensitive needs of the consumer population. Definition of Cultural Competence Cultural competence refers to an ability to interact effectively with people of different cultures. Cultural competence is comprised of four components: Awareness of one's own cultural worldview, An open attitude towards cultural differences, Knowledge of different cultural practices and worldviews, and Cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures. Cultural competence may also be associated with diversity. Diversity must be prevalent and valued before one may be considered a culturally competent or diversity competent organization. 28 CoastalCare believes in approaches and interventions that are based on, and targeted to, person centered results. The agency seeks to maintain an asking stance/partnership with the community. Methods and services that are culturally congruent and that allow individuals a voice in the behavioral health services and treatment they receive, are part of our commitment to our catchment area. CoastalCare leadership is invested and committed to cultural competence. Cultural competence touches every department of CoastalCare and the Providers who serve CoastalCare consumers and includes regular cultural competence monitoring. CoastalCare Network Management, Quality Management, and Quality of Care reviews will monitor compliance and audits of medical records, administrative files, the physical environment, and other areas of service including cultural competency reviews. CoastalCare responsibilities include use of the following mechanisms: a. Annual needs/gap assessment to measure the cultural and linguistic needs of the consumer population. The cultural and linguistic composition of the total population is assessed during this time; b. Obtains information/reports from the Health Call Center, Utilization Management, Customer Services, and the Care Coordination Directors related to utilization and access cases involving linguistics and ethnicity; c. Obtains reports from the interpreter services with whom CoastalCare contracts; and d. Expands and promotes cultural diversity activities designed to increase providers’ awareness in their quest to serve our growing, culturally diverse population. e. Based upon community cultural, racial, and ethnic composition, evaluate (and document) whether agency's existing location and physical appearance are respectful and representative of its community members and their culture. f. Contrast and compare who is currently served, to the population(s) present in the community. Identify gaps in available community resources, apparent service needs based upon who is being served, and request feedback from consumers and families utilizing the services. g. Consider stigma and its influence on the community to include unique cultural responses to people with mental illness. CoastalCare assures the Provider Network’s cultural competency awareness by the use of the CoastalCare Cultural Competency Plan and mandates that upon implementation of the CoastalCare Cultural Competency Plan that Providers comply with its direction in provision of mental health, developmental disability and substance abuse services. The goal is for each provider to create their own internal Cultural Competence Plan. Providers should set objectives 29 to address and identify mechanisms to renew, enhance, and increase staffs' cultural sensitivity, cultural awareness, and ability to provide culturally relevant services. Your responsibility as a CoastalCare Provider is to; Provide culturally competent services and ensure the cultural sensitivity of staff members Actively participate in community collaborative efforts to develop prevention, education and outreach programs Actively participate in the education of stakeholders and consumers on system access, services available, appeals and grievances, advanced directives and the provider network Earnestly participate in initiatives to achieve cultural competence Pursue the acquisition of knowledge relative to cultural competence and the provision of services in a culturally competent manner. To be responsive to the cultural and linguistic needs of the consumers your agency serves Review your agencies Mission/Vision/Values statements for inclusion of cultural competence Adhere to all cultural competence contractual elements Have access to appropriate self-awareness assessments for their agency determine the areas that are currently culturally competent Providers are encouraged to develop an agency specific implementation plan What changes should your program make to enhance cultural competence? Help staff learn more about local communities’ service needs and barriers to treatment Make it easier for consumers to use the services of this program Have the program’s décor better reflect the heritage of consumers and families using the facility Give persons from diverse backgrounds a greater voice in how services are delivered Other staff added ways to learn about beliefs, customs, norms or values of consumers and families served – and the diversity within these groups Help to build diversity of top staff through “in house” promotions Build contacts with those to whom local religious, ethnic or racial groups turn for leadership, guidance or aid Teach staff more about local community helping resources Attend to concerns of people who differ from the majority in culture or color, i.e., social justice and quality of life issues such as employment, housing and education 30 Advocate for, begin to use, or use more widely, instruments for consumer diagnosis or assessment that address cultural concerns. Send a stronger message that the program will not accept insults towards any race, religion or ethnic group Begin to use, or more widely use, or promote treatment that addresses cultural concerns. Network Providers will consistently demonstrate efforts to assure that their services eliminate the effects of any biases based upon individual and cultural factors. Cultural Competence Goal: CoastalCare’s Provider Network demonstrates cultural competence with the programs, services provided to consumers, and is responsive to the cultural, racial and ethnic differences of the populations served. CoastalCare’s mandate is, in part, that the system will reflect the uniqueness of our local communities and be shaped by the choices of consumers and their families. Cultural Competence extends beyond cultural sensitivities into the behaviors, attitudes, and policies that enable the system to work more effectively in cross-cultural situations. Provider Communication CoastalCare recognizes the vital role that communication plays in stable, productive, and successful relationships. Listed below are the most notable topics in regard to CoastalCare and provider communication including avenues for CoastalCare to disseminate information to its provider network. The CoastalCare Network Communication Plan has been developed to increase understanding of how providers can obtain needed information from CoastalCare as well as provide feedback on the various area authority functions. 1. Orientation and Training 2. The Provider Manual 3. Network Management Department 4. CoastalCare Website 5. Communication Memos 6. Local Provider Meeting 7. List Serve 8. Provider Council 9. Clinical Advisory Committee 10. Performance Improvement Teams 31 When CoastalCare implements changes that affect the Provider Network, information about those changes is communicated through official CoastalCare communication memos. Communication Memos are posted on the CoastalCare website and notification of the posting of new memos is relayed to providers via the list serve. All providers are welcome to add their email addresses to the CoastalCare list serve. The CoastalCare website contains a provider page with information specifically for providers including upcoming trainings, resources, a library of forms, details and minutes from the local provider meeting and access to all current and archived Communication Memos. Your responsibility as a CoastalCare Network Provider is to: Keep apprised of current information through the communication offered and provide services as per the most recent State standards or waiver service definitions; Attend and participate in Provider meetings in your area Review the web site for updates on a regular basis; www.CoastalCareNC.org Review the State web sites for most up to date information on a regular basis; www.dhhs.state.nc.us/mhddsas www.dhhs.state.nc.us/dma www.cms.gov Work in conjunction with CoastalCare staff for technical assistance CoastalCare Wilmington location: (910) 550-2624 CoastalCare Jacksonville location: (910) 459-4816 CoastalCare Morehead City location: (252) 648-3101 CoastalCare’s responsibility to you, the provider, is to: Offer Provider Meetings in two locations monthly and post the schedule on the www.CoastalCarenc.orgweb site under the provider tab Post official CoastalCare Communication Memos on the CoastalCare web page Send written correspondence via the mail as needed Assign a Network Management Liaison to each Provider to develop a personal working relationship and contact who can respond to individual provider needs Attend meetings with providers as needed to clarify issues or provide technical assistance Respond to provider inquiries and provide feedback in a timely manner. 32 Provider Council The Provider Council is one of the key structures of CoastalCare to ensure the perspective of providers is represented in network management decisions. as such, the council has responsibility to network providers in representing their interests and challenges, to consumers and family members and to CoastalCare in responding to standards, key indicators, initiatives and requirements. Mission: The CoastalCare Provider Council serves as a fair and impartial representative of all service providers within the network. The Provider Council shall facilitate open exchange of ideas, share values, goals, and vision and promote collaboration and mutual accountability among providers. The Provider Council strives to achieve best practices to empower consumers within our community to achieve their personal goals. The objectives for the Provider Council are as follows: Review and comment on Performance Indicators for network providers. Review and comment on Plans, Products, Guidelines, related to network management. Review and comment on provider payment policies or processes. Review and comment on Needs Assessment and Barriers to services/providers. Review and respond to Annual Provider Satisfaction Survey Review and comment on contracting process and provider selection criteria Review and comment on procedures related to the provider violation mechanism, sanction criteria and dispute resolution process. Review and comment on training needs and materials. Review and comment on QIPs Membership The Provider Council membership consists of currently active, Medicaid and state funded partners that represent the characteristics of the network – consumers served, geographic area covered and types of services provided. The Provider Council became operational in the June of 2012 and the current membership and a schedule of meetings can be accessed on the CoastalCare website under the provider page. Minutes are posted on the CoastalCare website and are on the provider page. Provider Enrollment and Credentialing As a part of the 1915 b/c Medicaid Waiver implementation, the Centers for Medicare and Medicaid Services (CMS) requires that each Area Authority credential and enroll providers in 33 the network. There are separate application formats, which must be completed and submitted based on the provider type. Applications are formatted to be typed or hand written. Licensed Independent Practitioners (LIP) Agencies Hospitals Credentialing All providers who are directly enrolled with the Division of Medical Assistance to provide behavioral health services must enroll with CoastalCare. Licensed Independent Practitioners (LIP) who are required to be credentialed include: Advanced Practice Psychiatric Clinical Nurse Specialist who is eligible to bill Medicaid under their North Carolina license Certified Clinical Supervisor Licensed Clinical Addiction Specialist (LCAS) Licensed Clinical Social Worker (LCSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Counselor (LPC) Licensed Professional Counselor Supervisor (LPCS) Licensed Psychologist (PHD Level) Medical Doctors, who employ clinical staff who bill “incident to” the physician’s Medicaid Provider Number Nurse Practitioner Physician Assistant Psychiatrists 34 Psychological Associate (LPA) Provisionally Licensed Clinicians who are employed by an agency LIP’s who bill Medicaid directly must enroll individually. LIP’s who are employed by an agency or group practice, must apply for enrollment at the same time (one complete packet) as the agency to be “associated with” the agency/group practice. CoastalCare is accepting applications from provisionally licensed practitioners who are employed by an agency and who bill Medicaid using the agency’s Medicaid Provider Number. Provisionally licensed clinicians who bill “incident to” a physician within a group practice will not be credentialed or enrolled at this time; however, the physician overseeing these services must be credentialed and enrolled with CoastalCare. Credentialing Application Review Credentialing Applications will be thoroughly reviewed by credentialing staff within the Network Management Department. If any information in an application is missing, incorrect, or inconsistent, providers will be requested to make corrections and/or submit additional information. As a part of the credentialing process, staff will conduct primary source verification and an evaluation of good standing status. Also, each credentialing applicant will be presented to the Credentialing Committee for a determination to approve or disapprove the application. Providers may request information regarding the status of their application at any time during the credentialing process. Providers are required to be recredentialed at least every three years. Primary Source Verification Primary source verification is defined as “verification based on information obtained directly from the issuing source of the credential”. Credentialing standards require that CoastalCare complete primary source verification of licensure. When possible the primary source verification will be completed through an on line process. When the applicable licensure board does not complete primary source verification of education, CoastalCare is required to do so. Boards that do not conduct primary source verification of education are: Medical Board NC Substance Abuse Professional Practice Board 35 When CoastalCare is required to conduct primary source verification of education, the LIP is required to request an official transcript to be submitted directly from the school or university. Evaluation of Good Standing Status “Good Standing” status as required for eligibility as a contracted provider is still in the process of being defined. The determination of “Good Standing” status for providers may be determined through a variety of means, including but not limited to: Office of Inspector General’s list of Excluded Individuals and Entities (LEIE) http://exclusions.oig.hhs.gov/ The Data Bank, to include the NPDB and HIPDB- http://www.npdbhipdb.hrsa.gov/index.jsp The NC Secretary of State Tax Lien databasehttp://www.secretary.state.nc.us/taxliens/filingsearch.aspx Medicare Exclusion Databases (MED) Inquiry of state agencies using the standardized Verification of Good Standing form. Excluded Parties List System (EPLS)- https://www.epls.gov/ Credentialing Committee CoastalCare’s Medical Director, who is an M.D., is responsible for oversight of the clinical aspects of the credentialing program and serves as the chair person for the Credentialing Committee. The Credentialing Committee consists of CoastalCare and provider agency staff that represent the composition of the network. The Credentialing Committee may request additional information regarding an applicant. Although a credentialing applicant can make corrections and submit additional information, the Committee may choose to factor in inconsistencies with the submitted information when making credentialing decisions. Only “clean applications” as defined in procedure, will not be individually reviewed by the committee. The Credentialing Committee is responsible for the following: Providing the overall direction of the Credentialing Program including review and approval of credentialing policies and procedures. 36 Approving or disapproving applications for network participation. The Committee may delegate authority to the Medical Director for approving clean applications. Discussing whether providers are meeting reasonable standards of care. Accessing appropriate clinical peer input when discussing standards of care for a particular type of provider. Maintaining Committee Minutes and documenting all actions. Evaluation and report to CoastalCare’s Management Team on the effectiveness of the Credentialing Program. Meeting as often as necessary to fulfill credentialing responsibilities, but no less than quarterly. Staff that have access to credentialing information and members of the credentialing committee will receive training regarding confidentiality of credentialing information. Each credentialing committee member and any staff that have access to credentialing information will sign a confidentiality statement. Access to credentialing information will be restricted to authorized personnel on a need to know basis. Performance Monitoring Local monitoring of Mental Health, Intellectual/Developmental Disabilities, and Substance Abuse provider agencies is one of CoastalCare’s oversight responsibilities. SB 163 monitoring rules were established to assure monitoring of Category A and B providers of mental health, Intellectual/Developmental Disabilities, and substance abuse services. Gold Star Rating and Monitoring Process The Gold Star Rating and Monitoring Process was adapted to standardize the monitoring process across the state and is consistent with the 1915 (b)/(c) Medicaid Waiver model and retains fidelity to that model pursuant to S.L. 2011-264. Specific information regarding provider monitoring including review tools can be found at: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/index.htm . An overview of the Gold Star Monitoring Process can be reviewed at: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/flowchart.pdf . The Gold Star Rating and Monitoring Process consists of an initial policy and procedure review, provisional , routine, preferred, exceptional and gold star profiles based on length of time in service provision within the CoastalCare network and request from the provider to move beyond the Routine Profile. 37 The Provider Performance Profile Grid gives an over view of the Gold Star requirements for each level. DHHS Provider Performance Profile Grid Noncontract providers 0 star Provider did not pass process Provisional Profile Routine Profile (Qualified and/or Probationary Status 6 months - 1 year) Preferred Profile (Commendable) Exceptional Profile (Excellent) Gold Star Profile (Achievement Plus) 1 star 2 stars 3 stars 4 stars 5 stars Review scores are less than 75% or significant issues are identified Maintain review scores between 75%-100% Maintain review scores between 80%100% Maintain review scores between 90%100% Maintain review scores between 95%-100% Review every 6 months Review Annually Review every 2nd year Review every 3rd year Review every 3rd year Per Qualifying Committee recommendation Provider meets all NC State Standards and contractual requirements Providers are required to meet all previous level requirements & ALL items listed below Providers are required to meet all previous level requirements & ALL items listed below Providers are required to meet all previous level requirements & ALL items listed below Serve consumer(s) a minimum of 90 days Serve consumer(s) a minimum of 1 yr Serve consumer(s) a minimum of 2 yrs Serve consumer(s) a minimum of 3 yrs Infrastructure for implementation of Independent CQI process where information/data is gathered and analyzed through CQI processes. (paper) Provider has established formal self monitoring quality management systems that generate data based results that includes a functional CQI process. Submit reports to appropriate committees. (actual implementation) Noncontract providers Terminated contract providers Providers new into system with no active consumers Provider completes and annual satisfaction survey Infrastructure for implementation of early CQI phases such as Independent CQI committee, CRC, Board of Directors with different members on each committee. 38 Beginning Best Practice trainings for staff Agency is beginning to focus on quality verses rules to define quality internally. Agency is beginning to identify, document, and measure quality/performance indicators Data & Outcome Driven system with formal goals and improvement projects Pursing National Accreditation Person Centered Service Plan is developed, implemented & includes natural supports Coordinated Planning process includes creative treatment, supports, utilizes & promotes natural supports Service Plan is person centered, culturally sensitive and documents staff training Provider completes a consumer satisfaction survey annually with results reviewed by internal committees. Agency consumer satisfaction surveys completed annually. Results used in a CQI process. Agency consumer surveys completed. Information analyzed with implementation for change. Provider completes exit interviews on staff leaving company. Staff surveys are completed annually. Agency staff surveys completed. Information analyzed with implementation for change = low staff turnover per agency data Implementing Best Practice trainings for staff Utilizing Best Practices for agency and has evidence to demonstrate Utilizes research based Best Practices in service delivery and staff training. Agency has ability to produce financial reports Infrastructure includes internal processes for maintaining financial balance. Includes internal audits, reviews & processes for paybacks. Provider reports regarding financial processes are reported to the agency committees (CQI, CRC, Board) Supervision & Training are occurring per agency requirements. Supervision occurs per the individual plan/contract and ensures professional growth. Focus ensures clinical management. Supervision occurs per an individualized plan/contract that encourages and promotes professional growth. Focus ensures clinical management as well as education. Professional Growth Plans are developed and implemented per staff with goals, timelines and strategies. 39 Provider has sufficient systems in place to manage submission of electronic information for billing, data reports, requests for authorizations, etc. Provider has sufficient systems in place to manage submission of electronic information for billing, data reports, requests for authorizations, etc. Provider has sufficient systems in place to manage submission of electronic information for billing, data reports, requests for authorizations, etc. Submission of Incident Reports, Restrictive Interventions and Level I Quarterly reports per state timeframes. Follow up is minimal and no POC required. Provider is beginning to identify patterns and trends on the utilization of restrictive intervention. Interventions are initiated to reduce restrictive intervention utilization. Provider is actively striving to serve consumers with "hands-off" approach. Data demonstrates a reduction in restrictive intervention utilization. Pursuing National Accreditation Pursuing National Accreditation Nationally Accredited Provider has a website available. Provider has an interactive website for consumers/family members to explore provider options. Serve on LME/MCO or state committee promoting reform &/or best practice training, mentoring,… Serve as model/mentor for other providers Once a Provider has been enrolled into the CoastalCare provider network, a policy and procedure review is completed. The provider must score 100% on this review and to be placed on Provisional Profile. After 90 days of service provision, an initial review is completed. The provider achieves Routine Profile after receiving a minimum score of 75% and stays at Routine Profile status for up to one year. After one year of service provision, a routine monitoring occurs. All providers with a Routine Profile are reviewed annually using the Routine Review 40 Tools, Cultural Competency Tool and the Billing Audit tool looking at 30 paid claims. After one year of service provision and moving forward, a provider may request to increase their profile level to Preferred, Exceptional or Gold Star Profile. In order to request a higher profile level, the provider submits a letter of intent and completes the Self-Assessment. Information on Self Assessments will be added as it becomes available. Once a provider achieves Preferred Profile, monitoring occurs every two years using the Preferred Review Tool, Cultural Competency Tool and Billing Audit Tool looking at 20 paid claims. Once a provider achieves Exceptional Profile, monitoring occurs every three years using the Exceptional Review Tool, Cultural Competency Tool and Billing Audit Tool looking at 15 paid claims. Once a provider achieves Gold Star Profile, monitoring occurs every three years using Gold Star Review Tool, Cultural Competency Tool and Billing Audit Tool looking at 10 paid claims. After achieving these levels, the next scheduled review consists of the Domain Review Tool, Billing Audit Tool and Cultural Competency Tool. Focused Monitoring Focused Monitoring is monitoring which has a particular area of focus. Focused monitoring may be initiated based on the following but not limited to: procedural requirements, request by DHHS, as part of a quality improvement process. Focused monitoring may include staff from other departments within CoastalCare in conjunction with the Network Management Departments as well as outside groups such as CFAC, DHHS, etc. Types of targeted monitoring include but are not limited to: Monitoring of a particular service or services across providers Monitoring based on funding source Follow up monitoring after the addition of a new service Monitoring that results from a complaint Monitoring of a particular area of concern, such as First Responder requirements, consumer rights, incident reporting, quality of care, etc. Network (State Funded) Provider Monitoring Quantitative Record Review Quantitative Record Review (QRR) of a sample of consumer medical and billing records is completed for each provider. This process is different from the routine monitoring process described earlier in the manual. The Quantitative Record Review process is required in order to monitor the provision of public services in the catchment area pursuant to G.S. 122C-11. The Quantitative Record Review assures that services billed by providers are documented according 41 to the Records Management and Documentation Manual and the Person-Centered Planning Instruction Manual. These Manuals can be found at the following link: http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/index.htm. A standardized review tool is used to determine adherence to requirements. The QRR consists of a minimum of three percent (3%) of all Medicaid and State Funded (IPRS) paid claims for the two month period prior to the review date. Other sample sizes and timeframes may be determined if a request is made for target monitoring. Mystery Shopping CoastalCare values the satisfaction of consumers/family members/stakeholders with the services provided in the CoastalCare Network. CoastalCare has various ways consumer satisfaction is measured. This includes “mystery shopping”. The goal of this initiative would be to gather feedback on how various CoastalCare Providers perform during random and anonymous monitoring. This system is intended to provide information to identify the need for additional training of Provider staff. Changes in Qualification Status In order to link consumers to appropriate care, CoastalCare is diligent in maintaining a provider database with the current practice information submitted by providers. Providers shall notify Network Management in writing within one (1) business day of any changes in their status, including, but not limited to: Changes in licensure status Changes in privileging status with other accrediting organizations Pending citations Pending malpractice claim, etc. Providers shall notify Network Management in writing using the PROVIDER ADD/CHANGE FORM, located on the CoastalCare website within seven (7) days of personnel changes or information updates. This may include but is not limited to: Change in ownership Change in Management Proposed address changes Opening of new locations Changes in capacity Inability to accept new referrals Any proposed acquisitions 42 Any mergers Any pending investigation for Medicaid fraud Applying for Additional Services In order for a Provider to be considered for Additional Services: The Provider must be in “good standing” CoastalCare has established that there is sufficient need for the service(s) ; and The provider has submitted a CoastalCare Additional Service or Site Application with all the required elements to their assigned Network Management Liaison. The application and all required elements must be received within sixty (60) days of the date the application is mailed to the provider. If it is not received in this time frame, the Provider shall have to re-initiate the process. CoastalCare will: Provide technical assistance as requested, to providers interested in additional services/sites. Determine if there is an established need for the service(s). Document the date the CoastalCare Additional Services or Site Application was received and review the information to determine if the application and required documentation is correct and complete. Review the performance record of the provider for actions that resulted in suspension of referrals, findings from other oversight agencies, Provider Performance Profile scores as well as demonstration of quality and use of best practices. Network Management will review and render a decision on the completed application with-in forty-five (45) days. Implementation Review CoastalCare Network Management conducts service implementation reviews after the provider serves CoastalCare consumers for 90 days. During this review, implementation of the newly contracted service will be assessed. If the review identifies any out of compliance issues, a Plan of Correction may be required. 43 Network Development Plan CoastalCare has a formal, comprehensive and ongoing mechanism to ensure network sufficiency. The Network Sufficiency and Development Plan is developed, reviewed and approved annually by CoastalCare Network Development and Management Committee. The CoastalCare Quality Management Committee provides management oversight of the plan and reviews and approves it annually against larger system goals. The Network Sufficiency and Development Plan is revised as needed throughout the year when significant changes to the network occur and as data about the network becomes available. The plan is developed and implemented based on: o the defined scope and type of services offered o the geographic area covered o the linguistic and culture-based preferences of consumers o the eligible population served It includes strategies for developing and managing an array of mental health, substance abuse and developmental disability services that emphasizes service quality, service access and availability, best-practice models and maximizes sound use of available funds. CoastalCare ensures that eligible consumers have timely and easy access to the behavioral health and developmental disability services offered in CoastalCare geographic area. CoastalCare also ensures that network providers have availability to meet the needs of consumers based on intensity of need criteria. CoastalCare develops access and availability goals using industry standards and measures the actual performance of the network against these goals. These goals and performance data contribute to the network sufficiency assessment and plan. CoastalCare assesses the provider network to ensure that an adequate number of providers are available to meet the behavioral health and developmental disability needs of eligible consumers. 44 Access & Availability Monitoring CoastalCare measures actual performance and need for services in comparison to established access and availability goals. This is accomplished by obtaining, reviewing and analyzing reports from the following sources on a monthly, quarterly, or annual basis: 1. Call Center Report Emergent, Urgent, and Routine Care: This report is pulled from data submitted by CoastalCare Call Center. It is reported monthly and includes information for total number of consumers screened, percent scheduled within the required timeframe, and percentage compliance with goals for emergent, urgent and routine appointment benchmarks. The timeframes for each type of appointment are specified by contract and the Network Sufficiency and Development Plan. 2. Call Center Assessment Appointment Capacity Data: The Call Center Assessment Appointment Spreadsheet is a “snapshot” of provider appointment availability. The report is completed monthly, monitoring the calendar for number of daily appointment slots. The report indicates compliance/non-compliance with urgent and routine timeframe benchmarks (i.e. 48 hours or 14 days). The reports are trended and reported monthly to the Network and Development Committee. 3. Initiation and Engagement Measures: This report is pulled from paid claims data to measure network performance for service initiation (2 services in 14 days) and engagement (additional 2 services in the next 30 days) against the state minimum performance measures and CoastalCare established goals. A Provider Performance Profile is developed on a quarterly basis by the Quality Management Department. The report includes initiation and engagement data for individual providers in comparison to the network average and statewide goals. This report is sent quarterly to each provider by the QM Department. Specific information regarding Initiation and Engagement timeline requirements is included in the contract and the Provider Performance Profile. 4. Complaint Data: Complaints involving provider access are reported monthly. This report gives total number of complaints by provider; total substantiated complaints and benchmark measures related to number or frequency of substantiated complaints. 5. Paid Claims data: Paid claims reports are generated by the Network Management Department on a quarterly basis. These reports are used to monitor the total number of consumers served, as well as the amount and type of services claimed. 45 Need/Gap Analysis CoastalCare initiates a comprehensive process for gathering and analyzing information that identifies needs and gaps in service capacity in its five county geographic catchment areas. The needs/gap assessment serves as one mechanism to assess network adequacy and sufficiency. The annual needs/gaps assessment process includes: 1. Involving consumers, consumers’ family members, community stakeholders, CoastalCare Community and Family Advisory Committee (CFAC), CoastalCare Board of Directors, CoastalCare Management Staff, CoastalCare Provider Council Sub-committee and provider network participants; 2. Data collection strategies include: a. The distribution of electronic surveys sent to network providers; b. Surveys targeting consumers, significant community stakeholders, and CoastalCare’s Board of Directors; c. Community meetings where face-to-face discussions occurred; and d. Needs Assessment forums, with a focus on gathering information from consumers and stakeholders. 3. Geographic Information Systems to produce geo-access maps to define the service area and populations served. 4. CoastalCare has developed mechanisms to measure and address the culturally sensitive needs of the consumer population. CoastalCare uses the following mechanisms: h. Annual needs/gap assessment to measure the cultural and linguistic needs of the consumer population. The cultural and linguistic composition of the total population is assessed during this time; i. Obtains information/reports related to utilization and access issues which identify linguistics and ethnicity from the Health Call Center, Utilization Management, Customer Services, and the Care Coordination Directors; j. Obtains reports from the interpreter services with whom CoastalCare contracts; and k. Expands and promotes cultural diversity activities designed to increase providers’ awareness in their quest to serve our growing, culturally diverse population. 5. The assessment takes into consideration at least the following: a. Population in the catchment area; b. Identified gaps in the service array; 46 c. d. e. f. g. h. Number and variety of providers for each service; Access and availability goals; Service utilization rates; The cultural and linguistic competency of existing providers; Provision of evidence based practices and treatments; Availability of community services to address housing and employment issues; CoastalCare reports the results of the annual assessment to NC DMH, the Area Board and CFAC. CoastalCare demonstrates that it is engaged in development efforts to address service gaps and sufficiency needs identified in the assessment. CoastalCare Network Development Action Plan Monthly reports to the NDM Committee are used to develop strategic action plans to address performance concerns. Once established and finalized, these reports, plans and performance measures related to the action plan are included as part of the decision making process for the following: 1. Network development decisions, including Request for Proposal or Request for Information; 2. Network management decisions ; 3. Increased monitoring of network performance; 4. Contract selection decisions or revision of selection criteria; 5. Network sufficiency decisions regarding expansion or retraction of the network; 6. Revision of the access or availability goals; 7. Recommending a Quality Improvement Project to address the deficient area; Contracts CoastalCare must enter into Procurement Contracts with Network Providers before any services can be authorized or paid. Network Providers are required to have a fully executed CoastalCare Contract which lists services and approved sites prior to the delivery of services to a CoastalCare Consumer. The CoastalCare contract is divided into two sections: a Procurement Contract and a set of General Conditions. The Procurement Contract is customized for the following types of providers: 47 • Agency • Agency: PRTF • Agency: ICF-MR • Agency: Innovations • Agency: Specialized Innovations • Licensed Independent Practitioner • Hospital: Inpatient • Hospital: Inpatient and Outpatient There are three versions of the General Conditions: One for Agencies, one for Licensed Independent Practitioners, and one for Hospitals. The General Conditions describe compliance according to federal and state regulations and CoastalCare’s waiver participation. All the CoastalCare contract templates have been approved by the Secretary of the Department of Health and Human Services as required by G.S. 122C 142(a). CoastalCare will enter into consumer-specific contracts with providers in order to meet the needs and requirements of consumers. A provider with a consumer specific contract is not considered to be a full member of the CoastalCare provider network and is not available as a choice for other consumers. The CoastalCare Provider Manual is incorporated into the contract by reference. As such, the policies, procedures and descriptions in the manual are considered a part of the service contract. (HN-10) Regarding employment agreements, all provider agency subcontractors are subject to all the provisions of the original contract. The Provider Manual defines the scope of processes, delineates procedures, provides updated information on network regulations, benefit plan and claims processing and specifies all URAC required inclusions and exclusions. CoastalCare excludes any contract language that restricts participating providers from discussing treatment options and other matters relevant to consumers’ health care, or that defines “medical necessity” in a manner that emphasizes cost/resource issues above clinical effectiveness. Participating Network Provider Contracts and the Provider Manual are issued annually as part of the annual contracting process. Prior to finalizing of the annual contract, the Network Management Contract Administrator ensures all required inclusions and exclusions are part of the binding legal process and documents. 48 Events that may result in the reduction, suspension or termination of network participation privileges include repeated non-performance of contract obligations without corrective action, violations of professional standards or the commission of unlawful acts. Examples of the above may include the following: loss of licensure, loss of credentialing, failure to maintain the required minimum insurance coverage, substantial failure to meet the contract or service description requirements, or findings of serious/on-going consumer health and safety violations. AGENCY AND LIP CONTRACTS Provider Agency and LIP responsibilities are to: • Review the Contract for accuracy and fully execute the Contract and return it to CoastalCare within thirty (30) days of receipt to assure payment for services. • Sign and have a fully executed CoastalCare Contract Amendment for any material changes to the original Contract. • Submit any required reports or data elements as required in the Contract to remain in good standing. • Submit reports as required in attachments and adhere to reporting requirements. • Understand the obligations and comply with terms of the Contract and all requirements in the CoastalCare Provider Manual. • Notify CoastalCare of any prospective changes in sites, ensure that all CoastalCare requirements are met and that any contract amendments are in place prior to delivery of contracted services. • Attempt to first resolve any disputes with other network providers or CoastalCare through direct contact or mediation. 49 • Notify CoastalCare in advance of any mergers or change in ownership since it may have implications for contract status. Minimum Criteria and Conditions to Participate in the Network Medicaid All of the following requirements must be met to participate in the CoastalCare Medicaid network: 1. 2. 3. 4. 5. 6. 7. 8. be eligible to do business in North Carolina have a current North Carolina license, if required for the service have a current accreditation, if required for the service have insurance coverage with the minimum required coverage limits have the ability to send & receive electronic claims files submit a correct and complete application for enrollment be credentialed by the CoastalCare Credentialing Committee have a fully executed Medicaid contract with CoastalCare State Funded Network To participate in the CoastalCare state funded network, a provider must meet requirements 1-7 above and 1. Meet CoastalCare selection criteria 2. Have a fully executed state funded contract with CoastalCare Immediate Suspension CoastalCare has defined the criteria and established clear procedures to utilize in order to immediately suspend a provider as a result of significant risk to consumer health, welfare and safety. Any circumstance or concern that may pose a significant risk to consumer health, welfare or safety is immediately reviewed by the Medical Director. Based on that review, the Medical Director may immediately suspend a participating provider’s participation in the network. When suspension occurs an expedited investigation is initiated and the provider is notified of the suspension. The provider is also notified of their right to access the CoastalCare dispute process. For additional information, see the Problem Resolution, Disputes & Appeals section below. 50 Criteria for Suspension based on Significant Risk to Consumer Health, Welfare, Safety o Health- Maintaining the general condition of well being of the consumer. o Welfare- Ensuring the physical, social, and financial conditions of the consumer is maintained satisfactorily while under the providers’ care. o Safety- Protection from, or not being exposed to, the risk of harm or injury. o Abuse is: o Medical Abuse is the improper or excessive use of treatment. o Psychological Abuse, also referred to as emotional abuse or mental abuse, is characterized by a person subjecting or exposing another to behavior that is psychologically harmful. o Physical Abuse- Injury, or other physical suffering or bodily harm. o Sexual Abuse is the forcing of unwanted sexual activity by one person on another, as by the use of threats or coercion or sexual activity that is deemed improper or harmful, as between an adult and a minor or with a person of diminished mental capacity. o Neglect is: o Disregard: lack of attention and due care to consumer needs, health, welfare, safety or the requirements of service; o Negligence: failure to act with the prudence that a reasonable person would exercise under the same circumstances. Training CoastalCare determines what training opportunities are provided based on: 51 Technical assistance needs identified throughout the network in routine monitoring Training funding availability Survey Results Training requests Training opportunities identified through trending provider requests for information and technical assistance, through provider survey, and/or through provider complaints and disputes Assessment of additional training needs is determined every year through the Provider Satisfaction survey process. The survey is disseminated electronically to the provider network annually during the first quarter. As part of the survey, providers have an opportunity to identify training needs. Additionally, providers can submit training requests via the website or directly to the Training Coordinator, who will submit them to the Training Committee. Additional assessment of training needs is conducted at the time of the annual training plan. At this time, the agency solicits input from the monthly provider workgroup about training needs or request via their completion of a training request form. All information gathered and the criteria list located above are used as a basis for the development of the CoastalCare annual training plan. CoastalCare may partner with Southeastern Health Education Center (SEAHEC) and/or NC Council to negotiate training opportunities for participating providers based on criteria listed above. CoastalCare Provider Training Opportunities Technical Assistance Often providers need guidance or have questions regarding the services they deliver, both clinical and procedural. CoastalCare’s Network Management department is the avenue through which communication with providers primarily occurs. Network Management is responsible for disseminating important information to the provider network as well as being available to provide technical assistance. The goal of technical assistance is ultimately to teach the provider how to access the information that they need and occasionally to provide interpretation of state policies and procedures. The provider community and CoastalCare’s Network Management department have numerous options to accomplish communication and technical assistance. Both can occur in groups or on an individual basis. CoastalCare is not required to provide technical assistance in areas that would normally be considered standard operational responsibilities of a provider agency or to providers that have shown by history not to be able to assimilate previous technical assistance provided. 52 Group communication Group communication methods are used to communicate information that affects the entire network. They are used by CoastalCare to communicate to multiple providers at a time. They include: Website postings Website postings are used to communicate information to the public at large including the provider network. Postings can be about various topics from current events and highlights to job postings. CoastalCare web site (insert link) Communication Memos Communication Memos are the specific vehicle that CoastalCare uses to communicate on the website to the providers. These postings often include policy and procedure changes, benefit plan information, upcoming trainings, and specific needs of CoastalCare. Local Provider Meeting The Local Provider Meeting is held each third Thursday of the month. The location of the meeting is posted on the CoastalCare website as well as the meeting agenda, associated handouts, and any training information for the previous month. The Provider Meetings are usually attended by CoastalCare staff members. The Network Management department often presents information at the meetings and is available to answer questions. Other departments from CoastalCare sometimes attend to present information specific to their areas of focus. This is the best forum for two way communication between CoastalCare and the provider network as a group. List Serve At the Provider meetings, provider agency’s staffs are welcome to add their names to the CoastalCare provider List Serve. The List Serve is a group of email addresses that CoastalCare uses to communicate information that may be of interest or benefit to the provider community such as training information, residential home openings, community collaborative events, and network development information requests. To be added, contact Wendy Ramsay at mailto:[email protected] Provider Orientation 53 CoastalCare provides an annual orientation to all participating providers, prior to the beginning of the new fiscal year. The CoastalCare Contract Administrator notifies participating providers by mail of the dates, times and location of the annual orientation opportunities. The annual orientation opportunities are also posted on the agency website on the “provider’s page” under training. For flexibility, two dates are scheduled within two weeks of one another. In the event that a contract is added midyear, the Contract Administrator schedules and notifies the new provider of an individual orientation opportunity within one month of selection and prior to the contract begin date. The orientation training curricula includes topics determined to be necessary for successful utilization of CoastalCare resources as well as information specific to contracting with participating providers. Quality Improvement Workgroup The CoastalCare Quality Management Department facilitates a Quality Improvement Workgroup monthly that assists providers with questions that they have about the QM practices at their agencies. The QI workgroup meets the third Friday of every month at a host provider agency location. Providers are encouraged to attend. Individualized Communication CoastalCare communicates one on one with provider agencies as well. CoastalCare assigns all provider agencies a primary contact person within the Network Management Department. This person is the agency’s liaison with CoastalCare. A Network Management liaison can provide an agency with individualized assistance and problem resolution. CoastalCare Network Management Department Liaisons are available for technical assistance tailored to an agency’s individual needs. The liaison will make every effort to address questions directly or will coordinate with other departments to ensure that providers receive comprehensive resolution to questions. The provider agency’s contact person and the liaison may communicate through all the usual means of communication such as: Phone calls Phone calls are welcome. Liaisons return phone calls within two business days. Provider agencies are encouraged to direct their calls to their liaisons to best coordinate a resolution. Emails Emails are the most frequent form of communication. Providers are encouraged to submit their questions electronically for a quicker response. Emails are answered within two business days. 54 CoastalCare’s CONFIDENTIAL Email CONFIDENTIAL email is available for use by provider agencies to communicate with CoastalCare staff when any protected healthcare information (PHI) is included in an email. CoastalCare helpdesk will issue a password upon request. Certified Mail Certified Mail or receipt mail is used (and often required) by provider agencies and Network Management. Many of the procedures involved in endorsement require submissions or responses to be completed within a timeframe. Certified mail allows an outside party to document receipt/delivery of mail for clear objective initiation of timeframes. First class mail is also used for letters that do not require timeframes or receipt of delivery. Consumer Rights and Empowerment Rights of Consumers Consumer rights are protected in many ways. The Customer Service Office ensures the basic rights of consumers receiving mental health, intellectual/developmental disabilities, and substance abuse services within the catchment area are protected. Consumers shall be informed of their rights upon initial contact and annually thereafter. It is further the responsibility of all behavioral healthcare providers to provide training on consumer rights, and ensure employees are knowledgeable of and adhere to all consumer rights. An overview of Consumer Rights rules and policies may be found at: http://www.ncdhhs.gov/mhddsas/services/advocacyandcustomerservice/clientsrightslawrules. htm In accordance with 10A NCAC 27D.0201, all behavioral healthcare providers are required to inform consumers of their rights as follows: Written summary of consumer rights Right to contact Disability Rights Right to contact CoastalCare Customer Services line at 1-855-250-1539 55 Informed of rules expected to follow Protections regarding disclosure of confidential information Procedure for obtaining Person Centered Plan Fee assessment Complaint procedure Suspension and expulsion from service Search and Seizure Additionally, for the consumer whose treatment/habilitation is likely to include the use of restrictive interventions, or for consumers in a 24-hour facility whose rights may be restricted, the consumer/guardian shall be informed of: Goals and reinforcement structure of any behavior management system Potential restrictions or potential use of restrictive interventions Notifications regarding emergency use of restrictive intervention procedures Notifications after use of restrictive interventions As a safeguard to ensure that consumers are informed about their rights, one of the goals of Customer Services is to provide helpful and easy to-understand information about the service system. The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services developed the Consumer Handbook to help guide and assist individuals seeking services and supports from the public mental health, developmental disabilities and substance abuse service system. It includes information about how to access services, person-centered planning, crisis services, rights and responsibilities of consumers, and helpful contacts and resources. This Division handbook is available via the Division website at: http://www.ncdhhs.gov/mhddsas/services/consumerhandbook/index.htm and on the CoastalCare website, along with CoastalCare’s Handbook at: http://www.CoastalCarenc.org/index.php?content=consumers&catid=35 Both an online and large print version of this handbook is available at the above website. Effective June 19, 2008, (per Communication bulletin #94) all Local Management Entities (LMEs) and behavioral healthcare providers are required to make printed versions of the Consumer Handbook available to consumers, family members and the general public. This handbook is in PDF format which can easily be printed and distributed locally to ensure that all consumers receive this information. 56 The Area Board bears the ultimate responsibility of ensuring and protecting the rights of consumers. The board carries out this responsibility by requiring that the Area Director equally work toward the objective of safeguarding and ensuring the health, safety, and rights of consumers. The Area Board has also established a Human Rights Committee, which meets at least quarterly to review information pertinent to consumer rights. The Office of Customer Service is responsible for responding to complaints, concerns, and information requests, as well as promoting education and information to consumers, families, agency staff, and provider agencies on consumer legal rights. Informed Consent Consumers have the right to be informed in advance of the potential risks and benefits of their treatment options. Upon service initiation, all behavioral healthcare providers are required to obtain: Informed written consent for treatment Informed written consent for planned use of a restrictive intervention [27D .0303(b)] Written consent granting permission to seek emergency care from a hospital or physician Informed written consent for participation in research projects Written consent to release information [26B .0202 and .0203] Documentation of written notice given to the individual/legally responsible person upon admission that disclosure may be made of pertinent confidential information without his or her expressed consent in accordance with G.S. § 122C-52 through 122C-56. Consumers also have the right to consent to or refuse any treatment unless: It is an emergency; The consumer is under involuntary commitment; Treatment is court-ordered; The consumer is under eighteen (18) years of age, has not been emancipated, and the consumer’s guardian or conservator gives permission for treatment. Psychiatric Advance Directives (PAD) In 1997 North Carolina developed a way for mental health treatment consumers to plan ahead for mental health treatment they might want to receive if they experience a crisis and are 57 unable to communicate for themselves or make voluntary decisions of their own free will. A statutory form for advance instruction for mental health treatment is provided by § 122C-77 of the North Carolina General Statutes. An Advance Directive for Mental Health Treatment allows Consumers to write down treatment preferences or instructions if they had a crisis in the future and could not make their own mental health treatment decisions. The PAD is not designed for people who may be experiencing mental health problems associated with aging, such as Alzheimer’s disease or dementia. To address these issues, a general health care power of attorney is used. A Psychiatric Advance Directives Document can include a person’s wishes about medications, ECT, or admission to a hospital, restraints, and whom to notify in case of hospitalization. The PAD may include instructions about paying rent or feeding pets while the consumer is in the hospital. The consumer could also put in an advance instruction “please call my doctor or clinician and follow his/her instructions.” That way if they are in an emergency room and unable to speak for themselves or confused, these instructions can be used as a means to help them at vital moments. The consumer must sign the Advance Directive for mental health treatment in the presence of two (2) qualified witnesses. The signatures must be acknowledged before a notary public. The witnesses may not be the attending physician, the mental health treatment provider, an employee of the physician or mental health treatment provider, the owner or employee of a health care facility in which the consumer is a resident, or a person related to the consumer or the consumer’s spouse. The document becomes effective upon its proper execution and remains valid unless revoked. If you are assisting a consumer in completing a Psychiatric Advance Directive, plan on several meetings to thoroughly think about crisis symptoms, medications, facility preferences, emergency contacts, and preferences for staff interactions, visitation permission, and other instructions. Upon being presented with a Psychiatric Advance Directive, the physician or other provider must make it a part of the person’s medical record. The attending physician or other mental health treatment provider must act in accordance with the statements expressed in the Advance Directive when the person is determined to be incapable, unless compliance is not consistent with G. S. 122C-74(g). This statute contains the generally accepted practice standards of treatment to benefit the consumer, availability of the treatments or hospital requested, treatment in case of an emergency endangering life or health, or when the consumer is involuntarily committed to a twenty-four (24) hour facility and undergoing 58 treatment as provided by law. If the doctor is unwilling to comply with part or all of the Advance Directive he or she must notify the consumer and record the reason for noncompliance in the patient’s medical record. Consumers can choose someone they trust (like a family member) to make treatment decisions for them if they cannot make the decisions themselves. This surrogate decision maker has Health Care Power of Attorney and functions as an Agent to carry out instructions of PAD. If the consumer does not have a PAD, the health care agent must make mental health decisions consistent with what the agent, in good faith, believes to be the wishes of the principal. The health care agent must be competent, at least eighteen (18) years of age, and not providing health care to the consumer for remuneration. The agent is not subject to criminal prosecution, civil liability, or professional disciplinary action for any action taken in good faith pursuant to an advance instruction. Under the Health Care Power of Attorney a person may appoint a person as their health care agent to make treatment decisions. The powers granted by this document are broad and sweeping and cannot be made by a doctor or a treatment provider under NC law. The Psychiatric Advanced Directive and Health Care Power of Attorney legal forms were designed by Duke University. They are available electronically at http://pad.duhs.duke.edu Confidentiality The Network Provider is required to ensure and maintain the confidentiality of all medical record information pertaining to all individuals served by them in the course of business. All confidential electronic and paper medical record information must be safeguarded and secured according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all applicable federal and state confidentiality laws, rules and regulations. This is to include 45 CFR Part 160 and 164, The Privacy Rule, and 42 CFR, Part 2 the confidentiality of substance abuse information in medical records. Confidential information should not be discussed, transmitted, or narrated in any form, except as authorized by the documented signature of a competent adult being served or the individual’s legally responsible person. A minor may authorize consent for release of confidential information under specific circumstances as outlined in APSM 45-1, Confidentiality Rules for Mental Health, Developmental Disabilities and Substance Abuse Services. Confidential information related to AIDS or related conditions can only be disclosed according to applicable communicable disease laws specified in G.S. 130A-143. 59 Secondary records, which contain information about a specific individual or individuals that can be personally identified, shall be protected with the same safeguards and security as the original service record. Providers shall be monitored and reviewed to ensure that they demonstrate through specific evidence their compliance with HIPAA and other federal and state Confidentiality laws in regard to the security and safeguarding with policy and procedure in regard to the individual’s served Protected Health Information (PHI). Second Opinion Consumers have the right to a second opinion if they do not agree with their diagnosis, treatment, or the medication prescribed. If a consumer requests a second opinion, arrangements will be made through CoastalCare’s Clinical Operations. Consumers are informed of their right to a second opinion in the CoastalCare Consumer Handbook, which is made available to them at the time of their enrollment. Your Responsibility As A CoastalCare Contracted Provider Is To: Respect consumers’ rights at all times Provide continual education to consumers regarding their rights, as well as support them in exercising their rights to the fullest extent Be knowledgeable of, and develop operational procedures to ensure compliance with, all outlined statutes and regulations regarding consumer rights and the use of restrictive interventions and protective devices Maintain an ongoing knowledge of changes to the statutes and regulations and immediately alter operations to meet changes Provide information the consumer needs in order to decide among all relevant treatment options Provide information to the consumer about the risks, benefits, and consequences of treatment or non-treatment options Provide information to the consumer about their right to participate in decisions regarding their healthcare, including the right to refuse treatment, and to express preferences about future treatment decisions Be aware that requesting a second opinion is a right of all consumers and refer the consumer to contact the toll free CoastalCare Customer Service number if a second opinion is requested 60 CoastalCare’s Responsibility To Providers Is To: Develop and disseminate educational material related to accessing services, consumer rights and protection Reductions, Denials, Suspensions or Termination of Medicaid Services It is very important that providers understand the following rights so they may support the consumer’s request or make the request on the consumer’s behalf (must show written consent.) If the treating physician/practitioner/provider would like to discuss the case with the CoastalCare UM care manager or the physician, please call one of the CoastalCare Business numbers. There are times when a consumer’s request for services is denied, and there are times when a current service is changed (i.e. terminated, reduced or suspended) by CoastalCare Utilization Management. Denial A denial could occur if the criteria are not met to support a new authorization request for a service. Consumer/guardian will receive a letter by US Mail explaining this decision and how to request a Reconsideration Review. During this time, CoastalCare will not provide the requested service in dispute. Reductions, Suspension, or Termination Services that a Consumer is currently receiving may be reduced, suspended or terminated based on several different factors including not following clinical guidelines or not continuing to meet medical necessity for the frequency, amount, or duration of a service. Consumer/guardian or authorized representative will receive a letter by US Mail at least 10 days before the change occurs explaining how to request a reconsideration. If consumer/guardian or authorized representative requests reconsideration by the deadline stated in the letter, the services may continue through the end of the original authorization. EXCEPTION: Decisions involving a reduction, termination or suspension of services In order to continue with existing services during an Appeal review and/or Appeal Process, the consumer/guardian/authorized representative must request Appeal within 10 days of the date of the Notice of Decision Letter. 61 The services will then continue until the end of the original authorization period as long as the Consumer remains Medicaid eligible. This right to receive services applies even if the consumer changes providers. The service will be provided at the same level the Consumer was receiving the day before the decision or the level requested by Consumer’s provider, whichever is less. The services that continue must be based on Consumer’s current condition and must be provided in accordance with all applicable state and federal statutes and rules and regulations. (See note on consumer/guardian responsibility for payment if adverse decision is upheld by DHHS.) **This does not apply for the denial of an initial service request** Due Process for Medicaid Decisions Detailed information about Due Process and Prior Approval Procedures can be accessed via the Division of Medical Assistance (DMA) website. (See the Resources & Web Links section at the end of this Manual for website links.) Appeal Level I Under The North Carolina MH/DD/SAS Health Plan 1915(b) and NC Innovations Waiver 1915(c) all persons who do not agree with CoastalCare’s Notice of Decision on a request for Medicaid services are entitled to Appeal through the CoastalCare Appeal process. To begin the process, an appeal must be filed within 30 days of the date of the Notice of Decision. To request an appeal review, the appeal request must be completed and returned by fax, mail or in person. Consumer/guardian or authorized representative has the right to review any information used as part of the Appeal process. A CoastalCare Appeal Review is a local impartial review of CoastalCare’s decision to reduce, suspend, terminate or deny Medicaid services. A health care professional who has appropriate clinical expertise in treating the Consumer’s condition or disorder, and who was not previously involved in CoastalCare’s initial decision, determines the Appeal Decision. It can take up to 45 days from the date the Request for Appeal is received for a decision to be made by the LME. The consumer/guardian/authorized representative must complete the local appeal process with CoastalCare before requesting a hearing with the Department of Health and Human Services (DHHS) and Office of Administrative Hearing (OAH.) Steps to File an Appeal Request To request an CoastalCare Appeal, the consumer/guardian/authorized representative and/or the provider (in making the request on the consumer’s/guardian’s behalf or supporting the 62 consumer’s/guardian’s request with written consent) must complete and return the CoastalCare Appeal Review Form by one of the following methods: Calling one of the CoastalCare Business Numbers: 910-550-2600; or toll free 1-855-250-1539 Fax to 910-550-2665 Mail or deliver in person to: Quality Management Appeals Specialist CoastalCare 2023 S. 17th Street Wilmington, NC 28403 Upon completion of the appeal decision, if the consumer/guardian disagrees with the CoastalCare appeal decision, the consumer/guardian/authorized representative can then appeal the decision to both DHHS and OAH by filing a Request for Hearing, also known as the State Fair Hearing process. Expedited Appeal Review Process An Expedited Appeal Review may be requested by the consumer/guardian (or the provider in making the request on the consumer’s/guardian's behalf or supporting the consumer’s/guardian's request), if it is indicated that taking the time for a standard Review could seriously jeopardize the consumer’s life, health or ability to attain, maintain, or regain maximum function. If an expedited request is received, it is reviewed to determine if there is sufficient evidence to support the need for this type of request. If so, an Appeal Review will be completed within 72 hours and the consumer will be notified of the decision. If there is not sufficient evidence to require an expedited request, the consumer/guardian will receive verbal notice of the denial of their request for an expedited appeal review and written notice within 2 days and the process will follow the normal appeal timelines. Mediation - Level II Once the Appeal is processed, OAH or The Mediation Network of North Carolina will contact the consumer/guardian to offer an opportunity to mediate the disputed issues in an effort to resolve the pending appeal informally. If the consumer/guardian accepts mediation, it must be completed within 25 days of the request. 63 If the issues are resolved at mediation, the appeal will be dismissed and services will be provided pursuant the Mediation Agreement. If consumer/guardian does not accept the offer of mediation or the results of mediation, the case will proceed to a hearing and will be heard by an Administrative Law Judge with the Office of Administrative Hearings. This is referred to as the state Fair Hearings process. Appeal/Hearing - Level III Consumer/guardian must file an appeal with the NC Office of Administrative Hearings (OAH), Department of Health and Human Services and CoastalCare within 30 days from the date of the Appeal decision to the addresses listed on the form. This state level hearing is conducted by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH.) The hearing is scheduled to occur by telephone unless consumer/guardian requests to attend in person. Consumer/guardian will receive notice of the date, time and location of the hearing. The hearing will be scheduled at the consumer’s/guardian’s convenience in a location close to the consumer/guardian. If there are questions, the consumer/guardian may call the NC Department of Health & Human Services (DHHS) Division of Medical Assistance Appeals Unit toll-free at 1-800-662-7030 or at 919-855-4260. Ask for the call to be transferred to the DMA Appeals Unit, Clinical Policy and Programs. To learn more about the appeals process, contact the North Carolina Office of Administrative Hearings at 919-431-3000. Final Agency Decision - Level IV In the past, the North Carolina Department of Health and Human Services reviewed the administrative law judge’s recommendation and made the final decision. During the last Session of the General Assembly, legislation was passed that would make the decision of the Administrative Law Judge the Final Agency Decision. However, that change in law appears to conflict with federal Medicaid regulations, so the State has asked the federal Centers for Medicare and Medicaid Services for a ruling. That ruling has not yet been issued, so at the moment, it is not clear which agency will make the Final Agency decision. Regardless of which State agency makes the Final Agency Decision, if the consumer/guardian disagrees with the Final Agency Decision, they may retain an attorney and ask for a judicial review in Superior Court. 64 If the final resolution of the Appeal is not decided in the consumer’s/guardian’s favor, (meaning CoastalCare’s or DHHS’s action was upheld), CoastalCare may recover the cost of the services furnished to the consumer/guardian while the Appeal is pending. Non-Medicaid Service Appeal Process Non-Medicaid services are not an entitlement. Non-Medicaid Service Decisions regarding termination, reduction, suspension or denial of Non- Medicaid services are handled within the Utilization Management Department. If consumer/ guardian disagree with the Non-Medicaid Service Decision, s/he or authorized representative may fill out the Non-Medicaid Appeal form that accompanies the decision and return it to the CoastalCare Quality Management Department within 15 working days of the date of the non-certified notification letter. The Clinical Support Department acknowledges receipt of the grievance in writing via a letter to the appellant dated the next working day following receipt. The Non-Medicaid Service Appeal process maintained by CoastalCare provides an opportunity for the consumer, guardian, and authorized representative, ordering/treating provider and/or facility rendering service to submit information related to the case, including any documents, records, written comments, or other information that may be helpful in processing the appeal. Peer Reviewers who process the appeal consider all the information received from the consumer, guardian, and authorized representative, ordering/treating provider and/or facility rendering service, regardless of whether the information was presented during the initial clinical review. Consumer/guardian/authorized representative will receive a Clinical Review Decision conducted by a health care professional that has appropriate clinical expertise in treating the consumer's condition or disorder within appropriate timeframes. Timeframes for the appeal process, which are in accordance with the requirements of the NC Division of Mental Health/Developmental Disabilities/Substance Use Services (DMH/DD/SAS) and URAC--the external accrediting body--are documented in CoastalCare policies and procedures and are available upon request to any consumer/guardian, provider or facility rendering service. 65 If the appeal decision is to uphold the original non-certification, the written notification will explain that there is an opportunity to appeal the decision to the Division’s Non-Medicaid Appeals Panel, as well as the process for doing so. Non-Medicaid Appeal Request to DHHS If consumer/guardian/authorized representative disagrees with the Non-Medicaid Service Decision, s/he may submit the Non-Medicaid Appeal Request Form to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS.) The internal CoastalCare Non-Medicaid Service Appeal process must be completed prior to filing the Appeal Request form with the Division. The DMH/DD/SAS hearing office must receive the consumer’s appeal within 11 calendar days from the date on the CoastalCare Non-Medicaid Service Decision Clinical Review Notification Letter [N.C.G.S. 143B-147(a) and 10A NCAC 271 .0600-.0609]. If the 11th day falls on a weekend or holiday, the deadline is the next business day. A verbal appeal is not acceptable. The Non-Medicaid Appeal Request is reviewed by a panel of individuals designated by the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS.) The panel will issue their findings and decisions within 60 days of receipt of the Appeal Request form to both the consumer/guardian and CoastalCare Executive Director. Upon receipt of the panel’s findings and decisions, CoastalCare will issue a final decision based on those recommendations in writing within 10 days. This decision is final and there are no further appeal rights as set forth in NC GS 143B-147(a)(9). (See first paragraph under Final Agency Decision - Level IV heading above.) Receiving Services during the Non-Medicaid Appeal Process CoastalCare has the option of authorizing other Non-Medicaid Services that are appropriate. Services may be authorized for the duration of the Appeal Decision process at the discretion of CoastalCare. Other community resources may also be referred to the consumer for support. When a consumer/guardian/authorized representative files an Appeal for the denial of a new service, CoastalCare is under no obligation to provide the requested service during the review process. Consumer and Family Advisory Committee (CFAC) The CoastalCare Consumer & Family Advisory Committee (CFAC) is a committee mandated by state law and established to review, comment, and make recommendations on the content and 66 delivery of Behavioral Health Services in its own service area. Membership consists of Consumers and Family Members of Consumers who receive Mental Health, Substance Abuse and Intellectual/Developmental Disability Services. CFAC members may serve for a maximum of two (2) consecutive three (3) year terms. The CoastalCare CFAC has twenty-one (21) member positions and represents all five (5) counties in the CoastalCare service area,in all three (3) disability areas. The CFAC is a self-governing committee operating under its own by-laws, membership rules, and Procedures. CFAC serves as an advising committee to the CoastalCare Board of Directors and CoastalCare’s Executive Administration. Mission Statement: The Consumer & Family Advisory Committee, which represents and advocates for all Consumers and Families within the service areas of CoastalCare, has a mission to ensure that all consumers have access to, and receive, the best available quality services. Vision Statement: The Consumer/Family Advisory Committee envisions a working and effective partnership with Coastal Care that will ensure that the voices of Consumers and their Families will always be heard and considered, forming the basis of decisions made by CoastalCare to create positive changes and to establish availability of continuing evidence-based practices. Some of the ways in which CFAC ensures that Consumers and Families remain involved in oversight, planning, and improvement of services managed by CoastalCare are by: Membership on, contact with, and monthly reporting to the CoastalCare Board of Directors. CFAC representation and input on Coastal Care’s Operational Committees as follows: o Network Management & Development o Quality Improvement Committee o Customer Service & Call Center Committee o Community Coordination Committee o Clinical Advisory Committee As a self-governing committee comprised of Consumers of services and their families, CoastalCare’s CFAC has been a strong voice at CoastalCare, and in the community. Members are very active as advocates for higher quality care and are responsible for developing positive CFAC initiatives, always in close collaboration with CoastalCare staff and key community stakeholders. 67 CoastalCare has enjoyed a strong and mutually supportive relationship with its CFAC, and has come to rely upon its recommendations. This ongoing and constructive interaction has often resulted in important modifications and/or expansions of care in the service array through input from consumers and family members by means of recommendations identified in a comprehensive gaps and needs analysis. The CFAC meets every month on the third (3rd) Tuesday of the month. All meetings are open to consumers, family members, and the general public. There is time allotted for public comment and questions to the Committee, and all meeting minutes are recorded, transcribed, and made available on CoastalCare’s Website athttp://www.CoastalCareNC.org . Any consumer, family member, Provider, or member of the general public may bring questions or any issues of concern to the CFAC’s attention by attending any of the monthly CFAC meetings, or by sending an email directly to any individual CFAC members. Contact may also be made by contacting the CoastalCare CFAC Liaison, at 910459-4840 [email protected] . *If providers know of individual consumers or family members that would like to serve on this committee, they may advise or assist them by calling the CFAC Liaison, or by visiting CoastalCare’s Website for access to the application for membership. Benefit Package Eligibility The Provider must not employ any policy or practice that shows discrimination against enrollees on the basis of race, color, or national origin. Who Is Eligible for the Medicaid Waivers? The following must be met for an individual to be eligible for acceptance in the Waiver: Individuals must have Medicaid in a “covered eligibility group.” Covered eligibility groups include the following: Individuals covered under Section 1931 of the Social Security Act (TANF/AFDC) Optional Categorically and Medically Needy Family and Children not in Medicaid Deductible Status (MAF) Blind and Disabled Children and Related Populations (SSI) (MSB) Blind and Disabled Adults and Related Populations (SSI) (Medicare) 68 Aged and related populations (SSI) (Medicare) Medicaid for the Aged (MAA) Medicaid for Pregnant Women (MPW) Medicaid for Infants and Children (MIC) Adult Care Home Residents (SAD) (SAA) Foster Care Children and Adoption Participants I Community Alternatives Programs (CAP/DA) (NC Innovations) (CAP-C) (CAP-MR/DD Medicaid recipients living in ICF-MR facilities Work First Family Assistance AAF) Refugee Assistance (MRF) (RRF) Medicaid County of Residence: Brunswick, Carteret, Onslow, New Hanover, or Pender Eligibility for individuals meeting the criteria listed above is mandatory and automatic. Children become eligible the first day of the month following their third birthday for 1915(b) services, but can be eligible from birth for 1915(c). The NC Innovations Waiver (1915 c Waiver): NC Innovations Home and Community Based Waiver 1915 (c) may be enrolled at an earlier age. A person with mental retardation (intellectual disability) and/or a related developmental disability may be considered for Innovations funding if all of the following criteria are met: The individual is eligible for Medicaid benefits based on assets and income of the applicant whether he/she is a child or an adult The individual meets the requirements for ICF-MR level of care as determined by the CoastalCare Utilization Management Department. (Refer to the NC Innovations Operations Manual for the ICF-MR criteria) Lives in an ICF-MR facility or is at high risk for placement in an ICF-MR facility High risk for ICF-MR institutional placement is defined as a reasonable indication that individual may need such services in the near future (one moth or less) but for the availability of home and community based services. The individual’s health, safety, and well-being can be maintained in the community with waiver support The individual requires Innovations Waiver services The individual, his/her family, or guardian desires participation in the Innovations Waiver program rather than institutional services 69 For the purposes of Medicaid eligibility, the person is a resident of one of the five counties within the CoastalCare region Brunswick, Carteret, Onslow, New Hanover, and Pender counties. The individual will use one Waiver service per month for eligibility to be maintained. Effective April 1, 2010, new NC Innovations participants must live with private families or in a living arrangement with six or fewer persons unrelated to the owner of the facility . Qualifies for the Innovations Waiver and has been assigned a “Waiver” slot. Medicaid Waiver Dis-enrollment When an enrollee changes county of residence for Medicaid eligibility to a county other than Brunswick, Carteret, New Hanover, Onslow, or Pender; the individual will continue to be enrolled in The NC MH/DD/SA Health Plan until the disenrollment is processed the by the Eligibility Enrollment System at the state. Disenrollment due to a change of residence is effective at midnight on the last day of the month. An enrollee will be automatically disenrolled from the NC MH/DD/SAS Health Plan if the following occurs: The individual moves to a county other than the CoastalCare counties The individual is deceased The individual is admitted to a correctional facility for more than thirty (30) days The individual no longer qualifies for Medicaid or is enrolled in an eligibility group not included in the NC MH/DD/SAS Health Plan or NC Innovations 1915 (b) (c) Waivers The individual is admitted to a state facility with more than sixteen (16) beds Eligibility for State Funded Services Enrollees that do not have Medicaid may be eligible for state funded services based on their County of residence and level of need. A consumer who meets eligibility requirements can be denied services based on inability to pay. State Funded Services are not an entitlement. CoastalCare and other LME/MCOs are not required to fund services beyond the resources that are available to them. There are also some services, including most residential services for adults that are not reimbursed by Medicaid. Therefore enrollees who receive Medicaid may also receive state funded services, based on their individual needs and availability of funding. CoastalCare maintains a Registry of Unmet Needs to track requests for state funding/nonemergency services that have not been met. Eligibility for Reimbursement by CoastalCare Consumers who have their services paid for in whole or in part by CoastalCare must be enrolled in the CoastalCare system. If you have any questions about a consumer’s eligibility, please call 70 the Customer Services line at 1-888-581-9988. Medicaid and state funds should be the payment of last resort. It is necessary that all other funding options be exhausted first. Enrollees with a Medicaid card from Brunswick, Carteret, New Hanover, Onslow or Pender counties are fully enrolled in the Coastal Care system and are eligible to receive Basic Benefit Services, Basic Augmented Services or Enhanced Benefit Services which have been authorized by CoastalCare. Medicaid regulations prohibit the use of Medicaid funds to pay for other than General Hospital Care delivered to inmates of public correctional institutions, and Medicaid funds may not be used to pay for services provided for enrollees in facilities with more than 16 beds that are classified as Institutions of Mental Diseases (IMD). IMD’s are hospitals such as the State Facilities because they have more than 16 beds and are not part of a general hospital. Enrollees with private or group insurance coverage are required to pay the co-pay assigned by their insurance carrier. NOTE: Provider contracts specify the funding source available for Provider billing. Providers should know if they have been contracted for Medicaid, State Services or both. If you have questions, please contact your assigned Provider Relations Representative. Enrollment of Consumers It is important for all providers to assure consumer enrollment data is up-to-date based on the most current CoastalCare Enrollment Procedures and training. These documents can be found in the NC MH/DD/SAS Health Plan Operations Manual and/or the CoastalCare website at http://intranet.secmh.org/. If enrollment data is not complete prior to service provision, authorizations and claims may be affected. Denial of authorizations requested and/or claims submitted for reimbursement may result from incomplete enrollment data. (See Section IX Finance for additional information). Service Eligibility: Services are divided into multiple service categories: Basic Services : The Basic Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent resources are available, to nonMedicaid individuals. These services are intended to provide brief interventions for individuals with acute needs. The Basic Benefit package is accessed through a referral from CoastalCare to an enrolled CoastalCare provider. Once the referral is made, there are no prior authorization requirements for basic services. Referred individuals can access a minimum of eight (8) visits for Adults ages 21 and up and sixteen (16) visits for Children and Adolescents below age 21. Basic Augmented Services: 71 The Basic Augmented Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent resources are available, to non-Medicaid individuals meeting Target Population criteria. An Enrollee requiring this level of benefit needs additional services than the automatically authorized eight (8) or sixteen (16) visits in order to maintain or improve his/her level of functioning. An Authorization for the services is available for this level and will need to be requested through the CostalCare Utilization Management Department. Authorization is based on the Enrollee’s need and medical necessity criteria for the service requested. Enhanced Services: The Enhanced Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent resources are available, to nonMedicaid individuals meeting Target Population criteria. Enhanced Benefit services are accessed through a person centered planning process. Enhanced Benefit services are intended to provide a range of services and supports, which are more appropriate for individuals seeking recovery from more severe forms of mental illness, substance abuse and intellectual and developmental disabilities with more complex service and support needs as identified in the person-centered planning process. The person-centered plan also includes both a proactive and reactive crisis contingency plan. Enhanced servicesinclude those services that are comprehensive, more intensive, and may be delivered for a longer period of time. An individual may receive services to the extent that they are not identified as necessary through the person-centered planning process and are not duplicated in the integrated services offered through the Enhanced Benefit (e.g., AssertiveCommunity Treatment). The goal is to assure that these individuals’ services are highly coordinated, reflect best practice and are connected to the personcentered plan authorized by CoastalCare. Target Populations: Target Population designation is for State funded services, it does not apply to enrollees who are only receiving Medicaid services. The Provider, through review of screening, triage and referral information and their assessment, must determine the specific Target Population for the enrollee according to the Division of MH/DD/SAS Criteria. Each Target Population is based on diagnostic and other indicators of the enrollee’s level of need. If the MH/DD/SAS system does not serve these individuals, there is no other system that will. The MH/DD/SAS system is a public safety net and its resources will be focused on those most in need. 72 To see the most current version of the Target Population Criteria, go to the IPRS Website link on the NC Division of MH/DD/SAS home page:http://www.ncdhhs.gov/mhddsas/iprsmenu/index.htm Service Definitions The regulations of a 1915 (b) waiver require that all NC Medicaid State Plan services be available under the 1915 (b) waiver. When the NC State Medicaid Plan changes the services covered under the NC MH/DD/SAS Health Plan will also change. Service Array For a listing of services, please refer to the most current version of the service arrays by benefit level and disability. For Mental Health, Substance Abuse and Developmental Disabilities, further detail can be found in the North Carolina Mental Health/Developmental Disabilities/Substance Abuse Services Health Plan Operations Manual. For the NC Innovations Waiver, further detail can be found in the NC Innovations Technical Manual. Hospital Admissions Medicaid consumers hospitalized on or after the effective date of enrollment by CoastalCare will receive authorization for all covered services, including inpatient and related inpatient services, according to Medical Necessity requirements. CoastalCare shall provide authorization for all inpatient hospital services to consumers who are hospitalized on the effective date of disenrollment (whether voluntary or involuntary) until such consumer is discharged from the hospital. Medicaid Transportation Services Transportation services are among the greatest needs identified to assist consumer in accessing care. It is PBH’s goal to assist consumers in accessing generic public transportation. Providers are requested to assist in meeting this need whenever possible. The Department of Social Services in each county has access to Medicaid approved transportation. Transportation is for medical appointments or getting prescriptions at the drug store. Riders have to call two (2) to four (4) days ahead to arrange a ride. There is no fee for consumers who are enrolled in Medicaid. For those who are not enrolled in Medicaid, transportation depends on available space, and there is a fee. For information on available transportation in your county please contact the local DSS http://www.ncdhhs.gov/dss/local/ 73 There are no special publically funded medical transportation services in the evening and on weekends. CoastalCare Clinical Design Plan Access, Enrollment and Authorization of Services Accessing Routine Services CoastalCare’s Access Standard for Routine Services is to arrange for services within 7 calendar days of contact with the Call Center. The geographic access standard for services is 30 miles or 30 minutes driving time in urban areas, and 45 miles or 45 minutes driving time in rural areas. Enrollment and Referral Process for Routine Needs 1. A resident of CoastalCare’s catchment area calls the 1-866-875-1757 Call Center number for a referral for services. 2. A consumer’s clinical need may be considered ROUTINE if, but not limited to, an indication that the consumer meets criteria for the presence of a benefit plan eligible DSM-IV TR Axis I or II disorder, and the consumer does not meet criteria for an emergent or urgent response. 3. The Call Center Clinician will search for the consumer in AlphaMCS. If the consumer is not found in AlphaMCS, the Call Center Clinician will collect and enter the initial enrollment information on the consumer via the AlphaMCS Enrollment Form, which contains information from the State mandated Screening, Triage, and Referral tool. If the consumer is found in AlphaMCS, the Call Center Clinician will update any changes in demographic information. 4. The Call Center Clinician will assess the consumer’s clinical needs by completing the Call Center’s Triage Assessment Tool to ensure the consumer is referred to the appropriate level of service. 74 5. The Call Center Clinician will offer the consumer a choice of three (3) providers (when available) based on the consumer’s clinical needs, preference in provider specialty/cultural competency, service availability, and proximity to the consumer. 6. The Call Center Clinician will schedule an appointment with the consumer’s chosen provider through the provider’s AlphaMCS calendar. If an appointment is not available within seven (7) calendar days of the chosen provider, the consumer may choose another provider. 7. If the Call Center Clinician began completing the AlphaMCS Enrollment Form, they will “hand over” the enrollment form to the chosen provider. The provider will be able to view the enrollment form in the AlphaMCS Provider Portal and will complete all required enrollment information, including documentation of Medicaid enrollment or ability to pay information, as well as completing the “Additional Clinical Page” upon conducting the assessment. The provider will then submit the completed enrollment form to CoastalCare’s Enrollment and Eligibility Specialist for review of completeness, accuracy, and verification of insurance eligibility. 8. The Call Center Clinician will also provide the chosen agency with the Call Center’s completed Triage Assessment Tool for that consumer through a secure electronic file to ensure the provider is informed of the clinical needs of the consumer at the time of the call. 9. The Call Center Clinician will follow up with the consumer within three (3) business days of the appointment if the chosen provider has indicated through the AlphaMCS Provider Portal that the consumer did not show or cancelled the appointment. Follow up will continue and will be documented in AlphaMCS until the Call Center Clinician has ensured that the consumer has been able to receive the care that is most appropriate to meet their clinical needs. CoastalCare Network Providers are held to the following DMA standard regarding Appointment Wait Time for ROUTINE Referrals: Scheduled -within one hour; Walk-in-within two hours. Accessing Urgent Services CoastalCare’s Access Standard for Urgent Services is to arrange for services within 48 hours of contact with the Call Center. The geographic access standard for services is 30 miles or 30 minutes driving time in urban areas, and 45 miles or 45 minutes driving time in rural areas. Enrollment and Referral Process for Urgent Needs 75 1. A resident of CoastalCare’s catchment area calls the 1-866-875-1757 Call Center number for a referral for services. 2. If the consumer calls any other CoastalCare number, and the call is determined URGENT, that call is immediately transferred to a Call Center Clinician via a “warm transfer” (Consumer remains on the line without being placed on hold.) 3. A consumer’s clinical need may be considered URGENT if, but not limited to the following: Consumer has moderate risk of harm to self or others (e.g. demonstrated risk factors with offsetting protective factors such as suicidal ideation without intent and presence of community supports). Consumer is demonstrating decompensation in functioning due to presence of psychiatric disorder, however, is not currently at imminent risk. Consumer of major recent environmental risk factor(s)/stressor(s) that increase the likelihood of decompensation in functioning due to presence of psychiatric disorder (e.g. death, serious trauma, major loss to support system). Consumer is using substances, likely meets criteria for treatment, and is amenable to same. Consumer is being released from incarceration and is in need of receiving follow up for treatment of a psychiatric illness. Consumer is being discharged from a community hospital, state hospital, or other crisis service. Consumer has a risk of loss of current stable living environment that is not immediate. 4. The Call Center Clinician will search for the consumer in AlphaMCS. If the consumer is not found in AlphaMCS, the Call Center Clinician will collect and enter the initial enrollment information on the consumer via the AlphaMCS Enrollment Form, which contains information from the State mandated Screening, Triage, and Referral tool. If the consumer is found in AlphaMCS, the Call Center Clinician will update any changes in demographic information. 5. The Call Center Clinician will assess the consumer’s clinical needs by completing the Call Center’s Triage Assessment Tool to ensure the consumer is referred to the appropriate level of service. 6. The Call Center Clinician will offer the consumer a choice of three (3) providers (when available) based on the consumer’s clinical needs, preference in provider specialty/cultural competency, service availability, and proximity to the consumer. However, the Call Center Clinician may determine that referral to Mobile Crisis Management or to a Crisis Response Center is more appropriate depending on the consumer’s clinical needs. 76 7. The Call Center Clinician will schedule an appointment with the consumer’s chosen provider through the provider’s AlphaMCS calendar. If there are no appointments available within 48 hours, the Call Center will offer the consumer an assessment by walking in to the chosen provider’s office between 8:00am-3:00pm. 8. The Call Center Clinician will reiterate to the consumer that CoastalCare’s Call Center is available 24 hours a day and advice the consumer to contact the Call Center at any time should their situation escalate and require an emergent referral. 9. If the Call Center Clinician began completing the AlphaMCS Enrollment Form, they will “hand over” the enrollment form to the chosen provider. The provider will be able to view the enrollment form in the AlphaMCS Provider Portal and will complete all required enrollment information, including documentation of Medicaid enrollment or ability to pay information, as well as completing the “Additional Clinical Page” upon conducting the assessment. The provider will then submit the completed enrollment form to CoastalCare’s Enrollment and Eligibility Specialist for review of completeness, accuracy, and verification of insurance eligibility. 10. The Call Center Clinician will also provide the chosen agency with the Call Center’s completed Triage Assessment Tool for that consumer through a secure electronic file to ensure the provider is informed of the clinical needs of the consumer at the time of the call. 11. The Call Center Clinician will follow up with the consumer within one (1) business day of the appointment if the chosen provider has indicated in the AlphaMCS Provider Portal that the consumer did not show or cancelled the appointment. Follow up will continue and will be documented in AlphaMCS until the Call Center Clinician has ensured that the consumer has been able to receive the care that is most appropriate to meet their clinical needs. 12. If a consumer requires an urgent referral, the consumer is referred to a provider regardless of funding status (Medicaid, Medicare, Insurance, etc.) CoastalCare Network Providers are held to the following DMA standard regarding Appointment Wait Time for URGENT Referrals: Scheduled Appointment -within one hour; Walk-in - within two hours. Accessing Emergent Services CoastalCare’s Access Standard for Emergency Services is two (2) hours or immediately, for lifethreatening emergencies. The geographic access standard for services is 30 miles or 30 minutes driving time. 77 In potentially life-threatening emergencies, the consumer’s safety and well-being has priority over administrative requirements. Eligibility verification will be deferred until the consumer receives appropriate care. Enrollment and Referral Process for Emergent Needs 1. A resident, family member or CIT officer of CoastalCare’s catchment area calls the 1866-875-1757 Call Center number for a referral for services. 2. If the caller calls any other CoastalCare number, and the call is determined EMERGENT, that call is immediately transferred to a Call Center Clinician via a “warm transfer” (Consumer remains on the line without being placed on hold.) 3. A consumer’s clinical need will be considered EMERGENT and will result in a “warm transfer” for an immediate Medical or Public Safety Referral if the consumer reports any of the following: Consumer is at acute risk of harming self or others, or of being harmed by others, and there is an imminent risk of death. Complaints of physical symptoms suggesting life-threatening conditions (e.g. chest pain) or conditions requiring medical attention (e.g. physical injury, overdose). Consumer is in possession of a firearm, other lethal weapon, or other lethal means with intent to use it and refuses immediate assistance. Consumer is exhibiting current or high risk of withdrawal symptoms that require immediate medical intervention (e.g. alcohol, barbiturate, or benzodiazepine withdrawal). Such symptoms may include history of recent seizures, tactile disturbances (itching, bugs crawling, pins, burning sensations), auditory disturbances, visual disturbances (e.g. light sensitivity, seeing things not there), headache, disorientation to date or situation. Consumer is experiencing acutely psychotic symptoms, is engaging in risky behavior, and is refusing community crisis response. Consumer is in immediate danger of harm by someone else. Family member or other party is reporting that a person is in immediate danger. 4. A consumer’s clinical need will be considered EMERGENT and will result in a “warm transfer” for a Community Crisis Response (i.e. Mobile Crisis Management or Crisis Response Center) if the consumer reports any of the following: Consumer is at acute risk of harming self or others, or of being harmed by others, but there is no imminent risk of death (e.g. suicidal ideation with intent and means, but agreeable to safety plan). 78 5. 6. 7. 8. Consumer is unable to care for self or is engaging in high risk/dangerous behavior due to symptoms of mental illness, substance abuse, or developmental disability. Presence of acute risk of loss of current stable living environment. Woman is pregnant and using alcohol or other drugs. Consumer is actively psychotic. Consumer is likely to experience withdrawal symptoms that require medical intervention, but is not in active withdrawal or likely to enter active withdrawal immediately. CIT officer is requesting immediate response The Call Center Clinician will assess the consumer’s clinical needs by completing the Call Center’s Triage Assessment Tool, including a referral safety and treatment plan, to ensure the consumer is referred to the appropriate level of service, and there are safety measures in place until the consumer is assessed by the Medical/Public Safety Provider or Community Crisis Provider. The Call Center Clinician will document their actions in AlphaMCS, and if referring to a Community Response Provider, will forward the completed Triage Assessment Tool for that consumer through a secure electronic file to them to ensure they are informed of the clinical needs of the consumer at the time of the call. If the consumer is not already enrolled in AlphaMCS, the Community Response Provider can complete and submit an enrollment through the AlphaMCS Provider Portal, or they can contact the Call Center to complete the enrollment on their behalf once the consumer has been assessed and stabilized. The Call Center Clinician will follow up with the Emergency Center or Community Crisis Provider within two (2) hours of the call. Follow up will continue and will be documented in AlphaMCS until the Call Center Clinician has ensured that the consumer has been able to receive the care that is most appropriate to meet their clinical needs. If a consumer requires an emergent referral, the consumer is referred to a provider regardless of funding status (Medicaid, Medicare, Insurance, etc.) Consumers are informed of the crisis services in CoastalCare’s catchment area through various methods, including the Consumer Handbook, other printed materials, and website postings. CoastalCare’s Network Providers are held to the following DMA standard regarding Appointment Wait Time for EMERGENT Referrals: The provider will see all Emergencies within two (2) hours. If the emergency is life threatening, the provider should contact the appropriate law enforcement agency, emergency medical services (EMS), or fire and rescue services. 79 Electronic Submission of Enrollments by Providers For Network Providers with access to the AlphaMCS Provider Portal, the following section outlines the process for how to submit enrollments for residents within CoastalCare’s catchment area who present to their agency by phone or in person. 1) Consumers who walk in to a provider site: a) The provider will assess the consumer for a life threatening situation. i) If the consumer presents with a life threatening situation, the provider will proceed with emergency response as clinically indicated. ii) If the consumer does not present with a life threatening situation, the provider will determine if the consumer is enrolled with CoastalCare (i) By checking the enrollment status in the AlphaMCS Provider Portal (ii) By calling the Call Center and asking about the consumer’s enrollment status. b) If the consumer is already enrolled in AlphaMCS, and the provider has verified with the consumer that they are not actively receiving services from another provider, the provider will conduct an assessment and request services as per CoastalCare’s Utilization Management Procedures. The provider should also ensure that the consumer’s demographic and clinical information is accurate and will complete a Clinical Update through the AlphaMCS Provider Portal if needed. c) If the consumer is not enrolled, the provider will complete all required enrollment information, including documentation of Medicaid enrollment or ability to pay information, as well as completing the “Additional Clinical Page” upon conducting the assessment. The provider will then submit the completed enrollment form to CoastalCare’s Enrollment and Eligibility Specialist for review of completeness, accuracy, and verification of insurance eligibility. 2) Consumers who call in to a provider site: a) The provider will assess the consumer for a life threatening situation. i) If the consumer presents with a life threatening situation, the provider will proceed with emergency response as clinically indicated. b) If the consumer does not present with a life threatening situation, the provider will schedule an appointment for an assessment, verifying with the consumer that they are not actively receiving services from another provider. c) At the consumer’s appointment, the provider will determine if the consumer is enrolled with CoastalCare i) By checking the enrollment status in the AlphaMCS Provider Portal ii) By calling the Call Center and asking about the consumer’s enrollment status. 80 d) If the consumer is already enrolled in AlphaMCS, and the provider has verified with the consumer that they are not actively receiving services from another provider, the provider will conduct an assessment and request services as per CoastalCare’s Utilization Management Procedures. The provider should also ensure that the consumer’s demographic and clinical information is accurate and will complete a Clinical Update through the AlphaMCS Provider Portal if needed. e) If the consumer is not enrolled, the provider will complete all required enrollment information, including documentation of Medicaid enrollment or ability to pay information, as well as completing the “Additional Clinical Page” upon conducting the assessment. The provider will then submit the completed enrollment form to CoastalCare’s Enrollment and Eligibility Specialist for review of completeness, accuracy, and verification of insurance eligibility. Registry of Unmet Needs CoastalCare maintains a Registry of Unmet Needs to track requests for non-emergency services that have not been met through either state-funded or non-entitled Medicaid categories. The purpose of the Registry is to allow CoastalCare and providers to coordinate services for consumers when the demand for services exceeds available State or non-entitled Medicaid resources, or when service capacity is reached as evidenced by unavailability of a provider for the service needed. Providers, consumers, or family members may initiate a referral to the Registry of Unmet Needs by contacting the Call Center at 1-866-875-1757. Your Responsibility As A CoastalCare Contracted Provider Is To: Publish and make available the toll free CoastalCare Customer Service and Call Center numbers for consumers and family members, along with the telephone number for the Disability Rights of North Carolina Provide and comply with face-to-face emergency care within two (2) hours (Emergent Request) of a request for services that is initiated by the Call Center or by the consumer; the provider must provide face-to-face emergency care immediately for life threatening emergencies Provide and comply with initial face-to-face assessments and/or treatment within 48 hours (Urgent Request) of the date and time a consumer requests your services through the Call Center or contacts you directly Provide and comply with initial face-to-face assessments and/or treatment within 5 business days (Routine Request) of the date a consumer requests your services through the Call Center or contacts you directly 81 Maintain systems and procedures to ensure consumers with scheduled appointments are being seen within the DMA required wait time of one (1) hour after their scheduled appointment time Maintain systems and procedures to ensure consumers who walk in are being seen within the DMA required wait time of two (2) hours after their arrival Maintain systems and procedures to ensure, for emergencies providers, staff provide emergency face-to-face care within the required timeframe of two (2) hours after the request for care is initiated by the Call Center or the consumer; life threatening emergencies shall be managed immediately Ensure there are no barriers to treatment, system navigation is courteous, and the screening process is the same no matter where the consumer presents to be seen Maintain systems and procedures to screen and triage consumer needs—whether by phone or walk in, and schedule that consumer for an appointment within the required timeframes Be as clear as possible in requests for information or services to enable our Call Center/Customer Service Office to help you in the most efficient and effective way possible Acknowledge all appointments scheduled by the Call Center in the AlphaMCS Provider Portal within 24 hours of the Call Center scheduling the appointment and update the status of the appointment to indicate the outcome Follow up with a phone call whenever a consumer misses their first appointment. Send a letter if unable to contact the consumer by phone and document all attempts to reach the consumer CoastalCare’s Responsibility To Providers Is To: Assess the satisfaction of consumers served Share natural and community resources for referrals and linkage Care Coordination Care Coordination is a function of CoastalCare to outreach and engage the consumers most vulnerable into the least restrictive levels of care. Care Coordination provides oversight of individuals who are high risk, high cost and/or who meet special healthcare needs population criteria ensuring the individual receives the most effective and efficient care possible while achieving an optimal level of recovery. With a holistic view of the member in mind, Care Coordinators monitor service delivery, identifying gaps in access, making connections to necessary and appropriate resources in the community, and ensuring appropriate plan development. Care Coordinators are responsible for ensuring that a member’s needs are 82 addressed, through establishing linkage to the most appropriate clinical services. Care Coordinators follow up with members and providers to ensure service engagement, monitor for goal attainment and the members overall status improvement. Constant monitoring of the appropriateness and accuracy of the Person Centered Plan/Individual Support Plan based on the consumer’s needs and status helps the Care Coordinator and the consumer’s treatment team make timely updates to improve the effectiveness and efficiency of services. There are three categories of consumer eligibility for Care Coordination: High Cost per NC General Statutes 122C-115.4 (1).(2) whose treatment plan is expected to incur cost in the top twenty (20%) percent of expenditures for all consumers in an age/disability o Includes Consumers on the Innovations Waiver High Risk per NC General Statute 122C-115.4 (1).(2) who has been assessed as needing emergent crisis services three (3) or more times in the previous twelve (12) months Special Healthcare Needs Pursuant to 42 CFR Part 438.208(c) o Currently or have been within the past 30 days in a facility operated by the Department of Correction, Department of Juvenile Justice and Delinquency Prevention o Using Drugs by injection within the last 30 days and have an opioid dependence diagnosis o Diagnosed within prescribed range and have a current CALOCUS of VI o Diagnosed within prescribed range and have a current LOCUS of VI o Diagnosed with substance dependence and have a current ASAM PPC level of III.7 or II.2-D or higher o Functionally eligible for, but not enrolled in, the Innovations waiver, and who are not living in an ICF-MR facility CoastalCare will identify and refer for care coordination services those consumers having high cost and/or high risk or who meet the criteria for a Special Healthcare Needs population. CoastalCare reviews the following information to identify high risk/high cost consumers: 83 Paid claims to identify the top 20% in cost utilization by age and disability Over or under utilization of services Community Care of North Carolina (CCNC) database to identify patterns of frequent hospitalizations, frequent admissions to the Emergency departments and psychopharmacology utilization. Local and State Psychiatric/ADATC hospitalizations High risk report that captures members who meet the established criteria CoastalCare has two Care Coordination units: one for Intellectual/Developmental Disabilities and one for Mental Health/Substance Use Disorders. Functions of Care Coordination include: Education about all available MH/SA/IDD services and supports, as well as education about all types of Medicaid and state-funded services Linkage to appropriate services, providers and monitoring for appropriate care Linkage to needed psychological, behavioral, educational, and physical evaluations Development of the Individual Support Plan (ISP) or Person Centered Plan (PCP) in conjunction with the recipient, family, and other all service and support providers Monitoring of the ISP, PCP, and health and safety of the consumer Coordination of Medicaid eligibility and benefits The Care Coordinator monitors services and plans for the consumer and works with the consumer and his/her treatment team to adjust these over time as necessary to achieve positive member outcomes. Examples of care coordination activities include: Providing follow up and engagement of high-risk consumers who do not appear for scheduled appointments Determining barriers to treatment and helping consumers overcome those barriers 84 Ensuring appropriate assessment and referral for services for consumers for whom a crisis service is provided as the first service Providing service monitoring and discharge planning for consumers who are hospitalized until they are connected with a clinical home Engaging consumers who frequent the emergency room to ensure they receive ongoing care that meets their needs instead of the intermittent care provided through ED services Ensuring appropriate, clinically sound consumer centered planning Promoting consumer recovery and community integration Monitoring consumers across CoastalCare’s system and with external systems including the medical and primary care systems to ensure best practice service delivery Making referrals and requests for services based on the solid assessments and plan as developed by the consumer’s team Monitoring service activity to see that the consumer received the care that was indicated. Quality of Care Care Coordination plays an important role in Quality of Care concerns. Depending of the level of concern Care Coordinators conduct a chart review and participate in treatment team meetings. Care Coordinators utilize Audit Tools (http://www.ncdhhs.gov/mhddsas/statspublications/presentations/qualityofcare/index.htm) to determine if an Independent Assessment is needed. If an Independent Assessment is needed then the Care Coordinator assists in referring the consumer to an Independent Licensed Professional. In conclusion of the review, the Care Coordinator makes recommendations and assists the provider if coordinating the best level of care for consumer. CCNC Collaboration Care Coordination and Community Care of North Carolina work together to integrate behavioral health providers and primary care physicians. This includes encouraging, supporting and facilitating communication between Primary Care Providers (PCPs) and behavioral health providers. Please refer to the follow link for more information: http://www.ncdhhs.gov/dma/services/FourQuadrantResponsibilities.pdf. To ensure the 85 collaboration Care Coordinators and the Community Care of North Carolina meet a minimum of once a month. System of Care (SOC) System of Care is a nationally recognized framework for organizing and coordinating services and resources into a comprehensive and interconnected network. Its goal is to work in partnership with children, youth, and families who need services or resources from multiple human service agencies to be safe and successful at home, in school, and in the community, and through this assistance, make the community a better place to live. Other Mental Health/Substance Use Disorders, Care Coordination, Coastal Care has two SOC Coordinators who work to build on individual and community strengths, and makes the most of existing resources to help children and their families achieve better outcomes. System of Care is the vehicle to achieve safety, permanence, and well being for children and families in North Carolina, from legislation, to state and local collaborative groups, to Child and Family Teams. Collaborative work is being done to ensure that children are successful in their homes, in school and in their communities. For more information on SOC see: http://www.ncdhhs.gov/mhddsas/services/serviceschildfamily/Toolbox/intro/i-whatissoc.pdf System of Care Coordinators The two CoastalCare’s System of Care (SOC) Coordinators provide information, training, and technical assistance to the community of child/adolescent mental health and substance use providers, community agencies, community collaborative committees and other stakeholders on the principles of System of Care and implementation of these principles to improve the quality of services to children and adolescents. The SOC coordinator: Ensures consumers are linked appropriately to providers and monitors provision of services and benefits to consumers Monitors effectiveness of the service delivery system through participation in Child and Family Team meetings. Facilitates the Juvenile Justice Mental Health and Substance Abuse Partnership, Community Collaborative for Brunswick, Carteret, New Hanover, Onslow and Pender counties and consultation to the five counties’ Departments of Social Services for Child protective services. 86 Crisis Services Care Coordination is provided for consumers who are being discharged from state facilities, hospitals, or crisis services (Emergency Department, NC START, Mobile Crisis) to link them to a clinical home provider. Care coordinators are assigned to participate in on-site discharge planning for consumers being discharged from the state hospital (Cherry State Hospital in Goldsboro), the alcohol and drug treatment center (Walter B. Jones ADATC in Greenville), the three-way bed contract at New Hanover Behavioral Health Unit and The Harbor (facility based crisis and detoxification). Care coordinators shall continue to work with the consumer and medical home until such time as the consumer is connected to a clinical home provider. Duties include: Monitor plan implementation periodically to ensure consumers stay linked to services and supports. Coordinate consumer transition from one level of care to another; particularly the transition from an institutional or more restrictive level of to a community service provider. Ensure the consumers are linked to a clinical home provider prior to discharge. Ensure providers engage and provide needed services following discharge. Innovations and Care Coordination Care Coordination is provided to consumers on the Innovations Waiver as well as other consumers meetings, High Risk, High Cost or Special Healthcare Needs. For consumers on the Innovations waiver, Care Coordination provides the following: Consulting with team members regarding consumer’s needs and care coordinator’s efforts on behalf of the consumer on an ongoing basis Facilitating service delivery process including re-assessment of level of care and annual reevaluation of needs and services Assisting in selecting a service provider 87 Monitoring to assure quality of care and health, safety and well-being as well as the continued appropriateness of services and supports including monitoring the ISP, Individual Budget and monitoring and coordination of all providers of service Identifying the need for a representative when the consumer desires to direct their own services and supports Ensuring ISP identifies how emergency back-up services will be addressed and coordinating provision of on-call emergency back-up services Recognizing and reporting critical incidents when necessary Assisting with grievances when necessary Answering any questions that arise, addressing problems in service provision, such as providing technical assistance and coordinating treatment team meetings Ensuring response to consumer crisis by identified providers and ensuring that needs are met and any updates to level of care or ISP are made and submitted based on changes in consumer needs Assuring access to specialized assessments Coordinating services with consumer’s CCNC medical home Arranging other needed Medicaid services Providing information on rights, responsibilities, and advanced directives Submitting ISP and authorization request for identified services needed to Utilization Management Department for service approval and ensuring approval of appropriate services including that services utilized do not exceed services authorized In addition Care Coordination monitoring includes: At least monthly face-to-face visits for new waiver consumers for the first 6 months. Then on a schedule agreed upon by the ISP team thereafter, but will receive a face-to face visit no less than quarterly to meet health and safety needs. For months that there is no faceto-face visit, telephone contact will be made to ensure that there is no issues that need to be addressed and the Care Coordinator will ensure that services utilized do not exceed services authorized. 88 At least monthly face-to-face for consumers whose services are provided by guardians and relatives living in the home of the consumer At least monthly face-to-face visits for consumers living in residential programs At least monthly face-to-face visits for consumers choosing the Individual Family Directed Supports option Intellectual or other Developmental Disabilities (I/DD) I/DD Care Coordination is also provided for consumers who are being admitted to or discharged from State Developmental Centers regular admission or specialty units, ICFMR residential facilities, or emergency services to link them to a clinical home provider. I/DD Care Coordination is provided to function as an institutional liaison for participation in on-site discharge planning for consumers being discharged from the State Developmental Centers (children at Murdoch Developmental Center in Butner, N.C. and adults at Caswell Developmental Center in Kinston, NC ), and the State Neuro-Medical Center for I/DD adults (O’Berry Neuro-Medical Center in Goldsboro, N.C.). This care coordinator shall continue to work with the consumer and the clinical home until such time as the consumer is connected appropriate services to meet their support Your responsibility as a CoastalCare Contracted Provider is to: Actively participate in a person centered planning process with others serving the individual to develop a comprehensive Person Centered Plan/Individual Support Plan Development of treatment and/or habilitative programs that are in accordance with the Person Centered Plan/Individual Support Plan Communicate with the Care Coordinators about the needs of individuals that you support Notify the Care Coordinator of any changes, incidents, other information of significance related to the consumer that you serve CoastalCare’s responsibility to Providers is to: Assessment: DD Care Coordinators will complete or arrange for needed assessments to identify support needs and to facilitate person centered planning processes. MH/SA Care Coordinators will complete or arrange for needed clinical assessments for individuals that have special health care needs in order to identify any ongoing special conditions that require treatment or monitoring. 89 Ensuring the Development of a Individual Support Plan: DD Care Coordinators will develop the Individual Support Plan in collaboration with the individual and his/her support team for consumers on the Innovations waiver. MH/SA Care Coordinators will ensure that a Person Centered Plan is developed by the Behavioral Health Clinical Home. (Person Centered Plans should be completed by the designated provider of an enhanced service.); Treatment Planning Care Coordination: Both DD and MH/SA Care Coordinators will coordinate services for individuals that have been identified as needing assistance to access the care that they need; activities will involve working across the CoastalCare Network and with other systems of care, including Primary Care. Monitoring: DD Care Coordinators will complete on site visits to monitor the health and safety of the individual, to assess the satisfaction of individuals served, and to monitor implementation of the Individual Support Plan. Service Definitions and Criteria Service Definitions describe the services that providers can be paid for in the state’s public system of MH/IDD/SA services. The definitions include descriptions of: Required components Provider requirements Staffing requirements, including experience, training, education Service types/settings Program requirements Utilization management Entrance criteria Continued stay criteria Discharge criteria Expected outcomes Service exclusions Service Array Medicaid Services For a listing of services, please refer to the most current version of the service arrays by benefit level and disability. For Mental Health, Substance Abuse and Intellectual/Developmental 90 Disabilities, further details can be found in Clinical Coverage Policy No. 8A of the Division of Medical Assistance website. See (http://www.ncdhhs.gov/dma/mp/8A.pdf) 1. NC MH/DD/SAS Health Plan – 1915(b) Waiver: The regulations of a 1915 (b) waiver require that all NC Medicaid State Plan services be available under the 1915 (b) waiver. When the NC State Medicaid Plan changes the services covered under the NC MH/DD/SAS Health Plan will also change. See also http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm 2. NC Innovations Waiver [1915 (c)]: The NC Innovations Waiver is a 1915 (c) Home and Community based waiver. The services defined under this waiver replace the CAP services under the NC CAP-MR/DD Waiver Plan. A consumer must be a member of the NC Innovations Waiver in order to receive these services. Please refer to the most current version of the Service Definitions on the DMA website. See also http://www.ncdhhs.gov/dma/mp/8M.pdf 3. B-3 Services: These are Medicaid services that are funded through a separate capitation payment. State Funded Benefit Plan Services available under the State Funded Benefit Plan are available to residents of CoastalCare’s 5 counties: Brunswick, Carteret, New Hanover, Onslow, and Pender. All individual consumers receiving services under this plan must be registered and active with CoastalCare through the enrollment process and the CDW system. The Benefit Plan is designed in order to promote the availability of scarce resources for a greater number of people. Authorization requests outside the benefit plan limitations will be returned as unable to process. When a service has reached budgeted capacity for the month any further authorization requests for that service will be returned as unable to process. A notice will be posted on the CoastalCare website any time we have reached our monthly capacity. Annual benefit applies to the state fiscal year which is July 1 – June 30. See also http://www.secmh.org/articles/Providers/IPRS/BenefitPlan.pdf and http://www.secmh.org/articles/Providers/IPRS/SvcCertMnthlyCap.pdf 91 Claims Information Enrollment and Eligibility Process Eligibility Determination All enrollees who have their services paid by CoastalCare must be enrolled in the CoastalCare system. Directions on patient enrollment can be found in the AlphaMCS Provider Portal Handbook. The Enrollment Master allows providers to enter all necessary information to enroll a client. Individuals who are at 100% ability to pay according to the sliding fee schedule established by the provider or who have insurance coverage that pays in full for their services, cannot be enrolled in the CoastalCare system. The individual may receive and pay for their services from a provider of their choice independent of CoastalCare. It is the responsibility of the provider to confirm the enrollee’s ability to pay prior to enrolling that individual into the CoastalCare system. This would require the provider to check the following items: Determine if the enrollee has Medicaid or is eligible for Medicaid. Determine if the enrollee has Medicare or any other third party insurance coverage. Determine if there is any other payer source – EAP program, worker’s compensation, court ordered services to be paid by court, etc. Determine if the enrollee meets CoastalCare criteria for use of state funds to pay for services. The criteria will be the lack of Medicaid or other third party insurance and the inability of the individual to pay for a portion of healthcare services based on the Sliding Fee Schedule established by the provider. Determine if the enrollee has previously been enrolled in the CoastalCare system. If the enrollee is eligible for Medicaid or has already been enrolled in the CoastalCare system, he/she is financially eligible for Medicaid reimbursable services from CoastalCare. Providers should assist enrollees in applying for Medicaid benefits at their respective county Departments of Social Services. Enrollment Data All providers are required to ensure enrollment data is up-to-date based on CoastalCare Enrollment Procedures. Reference/training information can be found at www.coastalcarenc.org by clicking on Training Guides and Training Videos. 92 CoastalCare eligibility staff review each enrollment form and make the determination of eligibility based on their rules. If the enrollment is approved the submitter is notified by e-mail and through the Provider Portal if appropriate. If the enrollment staff finds an issue with the enrollment form, the form will sent back to the submitter via Provider Portal with comments to allow the submitter to correct and resubmit. All Medicaid information must be provided when requesting an enrollment. If the enrollee has third party insurance, including Medicare, this information must be included in the enrollment request. Effective Date of Enrollment Enrollment in the CoastalCare system must be done prior to providing services with the exception of emergency situations. Events with service dates prior to the enrollment date will be denied. Crisis services provided in an emergency situation are an exception to this rule. In these cases, the provider has seven (7) days to complete the enrollment and indicate the date of enrollment as the date that the emergency service was provided. Patient ID The Patient ID Number identifies the specific enrollee receiving the service and is assigned by the CoastalCare AlphaMCS system. All claims submitted with incorrect Patient ID Numbers or for enrollees whose enrollment is no longer active will be denied. Coordination of Benefits CoastalCare will be the payer of last resort. Providers are required to pursue all applicable first and third party payments for services in order to minimize the usage of public resources. First party payers are the enrollees or their guarantors. Services paid with state funds are subject to the Sliding Fee Schedule established by the provider. Third party payers are any other funding sources that can be billed for the services provided to the enrollee. These payers can include worker’s compensation, disability insurance, or other health insurance coverage. All claims must identify the amounts collected from these first and third party payers. Providers should only request payment for any remaining amount. Eligibility Determination Process by Provider Providers should conduct a comprehensive eligibility determination process whenever an enrollee enters the system. Periodically (no more than every 90 days), the provider should 93 recheck eligibility information to determine if there are any first or third party payers for this enrollee. It is the provider’s responsibility to monitor this data and to complete Consumer Updates in the Provider Portal. Billing should be adjusted if there are additional payers. Obligation to Collect Providers must make good faith efforts to collect all first and third party funds prior to billing CoastalCare. First party charges must be reflected on the claim whether they were collected or not. The CoastalCare AlphaMCS system will incorporate both a Sliding Fee Schedule tracking function and a Client Deductible tracking function. Both functions will be based on the criteria as dictated under each Insurance/Benefit Plan. Reporting of Third Party Payments Providers are required to record on the claim either the payment or denial information from a third party payer. Copies of the Electronic Remittance Advice (ERA) or Explanation of Benefits (EOB) from the insurance company should be retained by the provider if they submit electronic billing. If paper claims are submitted to CoastalCare the provider will be required to attach paper copies of the ERA or EOB with the form. Providers must wait a reasonable amount of time in order to obtain a response from the insurance company without exceeding the 90 day rule before submitting claims. In the event that an insurance company pays after a claim has been submitted to CoastalCare, the provider must notify and reimburse CoastalCare. Process to Modify Consumers who become Medicaid eligible are not subject to Sliding Fee Schedules for Medicaid covered services, and payments should be adjusted immediately when this is determined. Sliding Fee Schedules Eligibility for Benefit Determination All enrollees must be evaluated at the time of enrollment on their ability to pay for services. In the case of crisis and emergency services, information must be collected at the first clinically appropriate occasion before submission of the first claim. This determination should be updated at least every 90 days to minimize the usage of public resources. Establishment of the Sliding Fee Schedule Prior to enrollment in the CoastalCare system, each enrollee must have completed the financial eligibility process to establish any third party coverage and to establish the ability to pay for services. The combination of an enrollee’s adjusted gross monthly income and the number of 94 dependents determines the payment amount based on the Sliding Fee Schedule established by the provider. Authorizations Required for Payment System Edits The CoastalCare AlphaMCS system is designed to check for proper authorization data prior to paying claims. A provider logs into Provider Portal and has the option of creating a new authorization request for an enrollee or choosing an existing authorization to use as a template. Providers will be able to utilize the Provider Portal to verify the status of their authorization requests. Authorization Number & Effective Dates Each authorization will be assigned a unique number, start date, and end date. Only services within this specific authorization will be paid. Dates and/or units outside of these parameters will be denied. Units of Service Each authorization will indicate the maximum number of units that were authorized. As each claim is processed, the system will perform an edit to make sure that the units being claimed fall within the units of service authorized and subtract that number of units. The system will automatically deny claims that do not fall within the authorization limits. Providers should establish their own internal controls to monitor their authorization usage and requests in order to prevent claim denials. Exceptions to Authorization Rule There are certain services that will be paid without an authorization. These services are limited in scope and are limited in total number to an enrollee. Once the annual limit has been reached for an enrollee, all services without a proper authorization will be denied. Providers must be diligent in tracking these limits in order to avoid denied claims. Payment of Claims & Claims Inquiries Clean Claims A clean claim is a claim that can be processed without obtaining additional information from the provider of the services or from a third party. It does not include a claim under review for medical necessity or a claim that is from a provider that is under investigation by a governmental agency for fraud or abuse. The clean claim criteria is consistent with state requirements and providers are educated on the agency clean claims criteria through initial 95 orientation, communication memorandums, provider manual, AlphaMCS Provider Portal Handbook, and the agency web site. Service Codes & Rates Provider contracts contain a listing of services which they are eligible to provide. All providers are reimbursed at the CoastalCare published rates for the service provided unless otherwise stated in their contract. Providers can submit claims for more than the published rates, but only the published contracted rate will be paid. If a provider submits a claim for less than the published rate, the lower rate will be paid. It is the responsibility of the provider to monitor the publishing of the rates and to make necessary changes accordingly. Standard Codes for Claims Submission Refer to CoastalCare website www.coastalcarenc.org for the following: CPT/HCPCS/Revenue Codes Diagnosis Codes Place of Service Codes Timeframes for Submission of Claims State Funded Services The agency shall honor provider billing for state funds that are filed in accordance with the agency’s contract with the provider. If the provider bills within sixty (60) days of providing a service, the agency will pay claims in accordance with the prompt pay requirements set forth as follows: within eighteen (18) calendar days after the agency receives a claim from a provider, the agency shall either (a) approve payment of the claim, (b) deny the claim, or (c) determine that additional information is required for making an approval or denial. If the agency approves the claim, the payment shall be made within thirty (30) calendar days after making approval. Medicaid Funded Services The agency shall honor billing for Medicaid funds that are filed in accordance with the agency’s contract with the provider. If the provider bills within ninety (90) days of providing a service, the agency will pay claims in accordance with the prompt pay requirements set forth as follows: within eighteen (18) calendar days after the agency receives a claim from a provider, the agency shall either: (a) approve payment of the claim, (b) deny the claim, or (c) determine that additional information is required for making an approval or denial. If the agency approves the claim, the payment shall be made within thirty (30) days after making approval. The agency shall ensure that ninety (90) percent of all clean claims for covered services are paid within thirty (30) days of the date of approval, and that ninety-nine (99) percent of such claims shall be paid within one hundred eighty (180 days of the date of receipt. The agency will not be 96 responsible for processing or payment of claims that are submitted ninety (90) days after the date of service unless coordination of benefits is involved (provider waiting on receipt of payment of denial from third party payer). Date of receipt is the date the agency receives the claim by Provider Portal or 837. The date paid is the date of the Electronic Fund Transfer (EFT). Multiple Occurrences of Same Service In a Day Specific services rendered multiple times in a single day must be (bundled) billed using multiple units rather than as separate line entries. This process prevents a duplicate billing denial. NPI (National Provider Identifier) It is mandatory for providers to obtain an NPI number to submit billing on the CMS-1500 and UB-04 forms. The AlphaMCS system captures and stores the provider’s and the individual clinician’s NPI and taxonomy codes. These codes are primarily used in the claim processing workflows for validating a provider or clinician. Verification of Receipt of 837 Electronic Billing File CoastalCare’s system provides the following responses to ensure that the electronic 837 is accepted into the AlphaMCS system for processing and payment: 997 File – This file acknowledges receipt of the 837 billing file. 824 File – This file contains feedback regarding whether line items in the 837 file have been accepted or rejected. If an item was rejected, a detailed explanation will be provided. In the event that there are errors found in the claim file, only those claims that contain errors will be rejected and the remaining clean claims will continue on to the AlphaMCS system. Provider Portal Direct Claims Submission Providers may directly enter their claims in CMS-1500 or UB-94 format through the Provider Portal. The provider selects the type of claim they would like to submit and chooses the enrollee they have served. The provider staff can create a new claim from a blank form or utilize a previous claim as a template to improve data entry efficiency. The AlphaMCS system will validate that all required fields have been properly completed. 837 Claims Submission Detailed instructions are available in the Information Management section of the Provider Manual. These instructions are very specific on what is required to submit claims electronically to CoastalCare. The entire testing and approval process is covered in this manual. CoastalCare will only accept HIPAA compliant transactions as required by law. CoastalCare provides the following HIPAA transaction files back to providers: 997 (acknowledgement 97 receipt), 824 (line by line acceptance/rejection response), and 835 (electronic version of the remittance advice). Process for Submission of Paper Claims CoastalCare will accept paper claims until providers can transition to electronic claims processing. An accurate CMS-1500 or UB-04 billing form with correct data elements must be submitted. CoastalCare staff will use the Internal Direct Data Entry (DDE) in AlphaMCS to enter the claim for the provider. The provider will be able to see the status of the claim regardless of the method of entry through the Provider Portal. Void and Replacement Claims Processing AlphaMCS includes functioning to void and replace claims. Processing begins based on the route and initiator of the submission. If the void or replacement claim is a paper claim or directly entered through Provider Portal, the AlphaMCS data base validates the claim and then attempts to match it to the original claim, then approves it to move through the claims process. A 997 report is produced for the provider, and if the claim is validated, it is sent to the AlphaMCS databse. At this point AlphaMCS attempts to match the claim to the original before approving the claim to move through the claims process. Clearinghouse Claims Routing AlphaMCS will allow providers to utilize clearinghouse services to submit compliant transactions including claims and eligibility. Transactions submitted through clearinghouse services will have the responses routed directly to the clearinghouse. The provider will continue to have full access to the status of the transaction through Provider Portal. Medicare Override Processing AlphaMCS will allow CoastalCare to designate services known to not be covered by Medicare or other insurance plans from requiring third party liability information to be submitted on the claim. This will allow for those services to be billed directly to CoastalCare without unnecessarily billing the primary insurance only to wait for a denial. Claim Denial Inquiries When a provider has a claim issue/denial question, the first step is to contact their assigned CoastalCare Claims Specialist for assistance by e-mail. Inquiries are made by sending an e-mail to [email protected] and the e-mails are assigned by the Track-It system to the appropriate Claims Specialist. All documentation regarding the inquiry is documented in the Track-IT system. If the provider is not satisfied with the resolution by the Claims Specialist, they should contact the Claims Manager directly. A response is made to the provider within one (1) business day. 98 Non –clinical claims appeals Quality Management will maintain a separate formal process to address appeals related to the non-clinical claims adjudication process. This formal process will be managed by the Appeals Specialist and will address claim adjudication appeals which shall include a mechanism to receive and respond to appeals within specified time periods, processes for prioritizing, investigating, and resolving appeals, protocols for written and verbal notification including explanation of final results and additional method for further review when applicable. Response to Claims 835 and Electronic Remittance Advice AlphaMCS will produce HIPAA compliant Electronic Remittance Advice forms and Outgoing 835 records after claims have been validated and approved through the AlphaMCS Claims Processing workflow. The generated ERA will be available to providers through Provider Portal. The 835 file can be used by the provider’s information system staff or vendor to automatically post payments and adjustment activity to their enrollee accounts. Providers are responsible for managing and monitoring their accounts receivables. Checkwrite Schedule and EFT Process A Checkwrite Schedule is posted on CoastalCare’s website to inform providers of dates of payment. Direct Deposit is mandatory for all provider payments. An Authorization Agreement for Direct Deposits is required to be completed by each provider along with a voided check or bank letter. Claims Investigations – Fraud & Abuse Trends of Use & Potential Fraud One of the primary responsibilities of CoastalCare will be to monitor the Provider Network for fraud and abuse. CoastalCare is responsible for monitoring and conducting periodic audits to ensure compliance with all federal and state laws and in particular the Medicare/Medicaid fraud and abuse laws. Specifically, CoastalCare validates the presence of material information to support billing of services consistent with Medicaid and State regulations. CoastalCare has the ability to generate random claims samples for auditing purposes to look for trends or patterns of abuse. Audit Process CoastalCare has the responsibility to ensure that funds are being used for the appropriate level and intensity of services as well as in compliance with federal, state, and general accounting rules. The CoastalCare Quality Management Unit is responsible for billing audits for all contract providers. 99 Voluntary Repayment of Claims It is the provider’s responsibility to notify CoastalCare in writing of any claims billed in error that will require repayment/recoupment. Providers are required to complete a Billing Correction Form. CoastalCare will make adjustments in the system and those adjustments will appear on a future Remittance Advice. Reporting to State & Federal Authorities For each case of reasonably substantiated suspected provider fraud and abuse, CoastalCare is obligated to provide DMA with the provider’s name and number, the source of the complaint, the type of provider, the nature of the complaint, the approximate range of dollars involved, and the legal and administrative disposition of the case. Repayment Process/Paybacks The Business Management Department is responsible for the recovery of funds based on any audit findings. CoastalCare will recoup the amount owed from future claims. If the payback amount exceeds outstanding provider claims, CoastalCare will invoice the provider for the amount owed. Providers will have thirty (30) calendar days from the date of the invoice date to reimburse the funds. If a provider fails to repay the funds identified, CoastalCare reserves the right to take action to collect the outstanding balance from the provider. Standards and Regulatory Compliance Introduction CoastalCare maintains a Quality Management Program which is a comprehensive, proactive program that provides the structure, process, resources, and expertise necessary to systematically define, evaluate, monitor and ensure that high-quality, cost-effective care and service are provided to consumers. The program is a commitment to continuous quality improvement principles and requires participation of the Area Board, providers, and staff members. The Quality Management Program of CoastalCare is designed to strengthen the mental health, intellectual/developmental disabilities, and substance abuse service delivery system, increase the quality of services delivered by network providers, improve service outcomes for consumers, and facilitate cost-effective care and service in an environment driven by managed care. As a Local Management Entity (LME) and Managed Care Organization (MCO), CoastalCare is committed to the provision of a Quality Management Program that focuses on health and safety, protection of consumer rights, achievement of outcomes, accountability, ongoing 100 system monitoring, and improvement in the system of care as consistent with the mission, vision, and values of the organization. Quality Improvement In a system driven by Continuous Quality Improvement, the Quality Management Program facilitates the objective and systematic measurement, monitoring, and evaluation of internal organizational processes as well as services delivered by network providers. Quality improvement activities are implemented as a result of the findings from these activities and measured periodically for intervention effectiveness. Within the organization, quality assurance is used as the foundation for quality improvement and provides information in guiding the improvement process. Information from quality assurance activities is utilized as a platform for data reporting and analysis and provides the opportunity for organizational planning and informed decision-making. Quality Improvement within the organization not only focuses on adhering to standards and statutory requirements, but also serves as the mechanism for emphasizing the agency’s commitment to excellence. CoastalCare Network Providers are also required to maintain a Quality Management Program that is comprehensive and proactive. The areas identified below provide a description of how CoastalCare’s Quality Management Department interfaces with the providers in the network. CoastalCare’s Quality Management Plan describes an in-depth overview of the Quality Management Program and agency quality management activities and can be found on the website at www.coastalcarenc.org. Provider Quality Management Plans On an annual basis, providers are required to submit their Quality Management Plans to the CoastalCare QM Department for review. QM staff utilizes the QM Plan Checklist as a tool in reviewing provider QM Plans and provides feedback on areas of strength and weakness to assist agencies in developing a viable plan that can be implemented within their organization for full effect. Technical assistance from the QM Department of CoastalCare is available upon request. The QM Plan Checklist is available on the CoastalCare website to support the plan development. Quality Improvement Projects The Provider’s Contract with CoastalCare requires all providers to complete three (3) annual Quality Improvement Projects that demonstrates evidence of performance improvement of some aspect of organizational processes or structures. Common QI projects are: improving access to treatment, improving consumer satisfaction scores, decreasing wait times for 101 psychiatric appointments, reducing duplication of paperwork, and implementing performance measures. The Quality Management Department of CoastalCare reviews the annual QI projects and monitors the outcomes from the QI Projects submitted by providers. Technical assistance is provided upon request. The QI Projects Checklist is available on the agency’s website at the link below to assist providers in reporting in QI projects: (http://www.CoastalCaremh.org/articles/QualityManagement/ProviderQIProjectChecklist.pdf). For questions or more information about QI projects or other QI activities you may contact the QM Systems Manager at (910) 550-2600 or [email protected] or the Director of Quality Management at [email protected]. Performance Measurement Data Collection and Verification CoastalCare is committed to quality care on a continuous and scientifically sound basis. In order to ensure compliance with contract requirements by DMA & DMH, CoastalCare currently monitors and measures performance indicators within the realms of various domains, such as Access and Availability, Appropriateness of Services, Quality of Care, Quality of Services, overall System Performance as well as Satisfaction. Performance Improvement In an ongoing effort to ensure and promote a culture of excellence within the realms of internal as well as external stakeholder performance and service delivery, CoastalCare thrives for full completion of its various Quality Improvement Projects, according to contractual standards. In addition to the overall system performance measures noted above, CoastalCare utilizes multiple measures to collect data on internal departmental performance. Information is collected quarterly and monthly, and data is entered into report forms and disseminated to the Management Team, the Quality Management Committee, and the Area Board. Provider Performance Profile In monitoring the performance of Providers in its network, CoastalCare utilizes a performance review system which targets specific quality initiatives for provider performance. Reliant upon these quality initiatives, providers are ranked by their performance into categories: Gold Star, Exceptional, Preferred and Routine. CoastalCare also monitors providers utilizing a system, solely based on Core Performance standards, in accordance with their contract. 102 North Carolina Support Needs Assessment Profile-NC SNAP NC-SNAP Requirements: NC-SNAP Assessments are required for all active Consumers with an Intellectual or other Developmental Disability (I/DD) diagnosis that are receiving I/DD services. Typically the NC-SNAP Assessment should be done in conjunction with the Person Centered Plan. NC-SNAP Assessments will be completed in accordance with protocols specified in the NC-SNAP Examiner’s Guide. All NC-SNAP Assessments are required to be completed by a Certified NC-SNAP Examiner. The Summary Report & Supplemental Information Sheet is required to be submitted with all NC-SNAP Assessments. NC-SNAP Assessments and the Summary Report & Supplemental Information Sheets are required when a consumer enters the I/DD service system. NC-SNAP Assessments and the NC-SNAP Summary Report & Supplemental Information sheet are due annually or if a significant change has occurred in the individual’s needs. The Care Coordinator has the primary responsibility for completing and submitting the NC-SNAP and NC-SNAP Summary Report & Supplemental Information sheet. If there is no Care Coordinator, the NC-SNAP Assessment and the Summary Report & Supplemental Information sheet will be completed by a certified NC-SNAP examiner (in order of preference): o Residential Provider o Day Program Provider o Respite Provider o Therapist The NC-SNAP Summary Report & Supplemental Information sheet is required for all discharges and transfers. NC-SNAP Examiner Certification Training NC-SNAP Certification is only available to those individuals with the appropriate credentials who are in a position that requires them to complete or review NC-SNAP Assessments as part of their job responsibilities. Typically, this is a Qualified Professional. To request NC-SNAP training, email Marianne de la Vega, Medical Records Specialist, at [email protected] for training registration at the Murdoch Developmental Center. 103 The following information is needed for the registration of training: Provider name, Title, and Agency. Provider phone number, business mailing address, and e-mail address. Training dates requested with a 1st and 2nd choice of dates. The Medical Records Specialist will e-mail the provider a confirmation notice of the training for them to take to the Murdoch Developmental Center, which is required for admittance. When requesting refresher training, please include the Examiner Certification number with the Provider name information. PLEASE NOTE: Examiner Certification privileges expire after twenty one (21) months of inactivity. Submitting Completed NC-Snap Assessments to CoastalCare The initial NC-SNAP Assessment and Annual Update Assessment is due to CoastalCare within 30 days of the admission or annual due date (i.e. the Provider has 13 months to submit the Annual Up-date to CoastalCare). The completed NC-SNAP Assessments should be submitted to the QM Department. The Provider is to submit only copies of the NC-SNAP Summary Report & Supplemental Information sheet and the Profile page (front page) of the NC-SNAP Assessment. The Provider is to keep the originals in the consumer’s record. The provider may submit the NC-SNAP Assessment and NC-SNAP Summary Report & Supplemental Information sheet to CoastalCare by one of the following ways: Fax to 910-550-2665, attention: Marianne de la Vega Secure email to [email protected] When a provider submits via fax/email, the provider will receive a confirmation email of receipt of the assessment. When submitting NC-SNAP assessments, the provider should check each assessment/Summary Report & Supplemental Information sheet to ensure that all required fields are accurately and entirely completed. All corrections made to the NC-SNAP should be lined through, initialed and dated. A new form should not be used when making corrections unless the assessment becomes illegible. Past Due Notices 104 CoastalCare will issue Past Due SNAP Notices on the 1st and 15th of the month. The Provider has 15 calendar days from the date of the Past Due notice to submit the NC-SNAP Assessment and NC-SNAPs Summary Report & Supplemental Information sheet. If the Consumer has been discharged or transferred, the Provider must submit the NC-SNAP Summary Report & Supplemental Information sheet. Blank NC-SNAP Assessment Forms An original NC-SNAP Form must be used for all assessments. CoastalCare receives a 6-month supply of blank NC-SNAP forms in January and July from the NC Department of Health and Human Services. This is based on the number of active I/DD consumers in the state NC-SNAP Database plus 1%. CoastalCare will distribute to each I/DD Provider responsible for NC-SNAP Assessments a 6month supply based on the number of active consumers in the state NC-SNAP Database plus 1%. CoastalCare will notify the providers in December and June of the consumer counts. The Provider is responsible for notifying CoastalCare if the count is incorrect. The Provider is also responsible for managing the 6-month supply and must sign a receipt for the blank NC-SNAP forms. The Summary Report & Supplemental Information Sheet may be duplicated. This form is available at CoastalCare’s website under the Provider’s Page at http://www.CoastalCaremh.org/index.php?content=providers&catid=47&desc=NC-SNAP. The state tracks the number of NC-SNAP forms requested and the number of assessments entered into the database. CoastalCare is responsible for ensuring that all Providers submit the NC-SNAP Assessment annually as part of the Performance Contract with The Department of Health and Human Services which is monitored by The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. CoastalCare NC-SNAP Contact information: Marianne de la Vega Medical Records Specialist 165 Center Street Jacksonville, NC 28546 Phone: 910-459-4860 105 Fax: 910-550-2665 E-mail: [email protected] For additional information about the NC-SNAP, visit the state’s NC-SNAP website at: http://www.ncdhhs.gov/mhddsas/providers/NCSNAP/index.htm North Carolina Treatment and Outcomes Program Performance System –NC TOPPS The North Carolina-Treatment Outcomes and Program Performance System (NC-TOPPS) is the program by which the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services measure the quality of substance abuse and mental health services and their impact on individuals’ lives. The web-based NC-TOPPS was implemented statewide in July 2005 for 100% of adults and children ages 6 years and above who are receiving services for mental health and/or substance abuse issues. A manual that details all the NC-TOPPS requirements can be found at: https://nctopps.ncdmh.net/dev/GettingStartedWithNCTOPPS.asp Online interviews conducted at initiation, (3 months, 6 months, 12 months), and at the end of an episode of care provide information on each individual’s service needs and outcomes. The responsibility for completing NC-TOPPS lies with the consumer’s primary provider agency. The initial interview must be completed with the consumer at the beginning of an episode of care during the 1st or 2nd visit. The Update Interviews (3, 6, and 12 months and Bi-Annual are to be submitted within the appropriate time frame as long as the consumer is receiving treatment. If the consumer is no longer receiving the qualified treatment, an Episode Completion is submitted. The NC TOPPS must be administered by a Qualified Professional. For more information on submitting the NC TOPPS or for training, you may contact Diocles Wells at (910) 550-2664 or at [email protected]. Performance Monitoring An important part of CoastalCare’s role as an MCO is to monitor performance of Providers in its network. The CoastalCare Quality Management Department is charged with data reporting and analysis and assists the various departments within the organization in monitoring internal performance as well as the performance of its network providers. Through the use of data, CoastalCare is able to identify areas of service delivery and outcomes that warrant improvements. CoastalCare may ask providers to implement specific quality improvement projects when data findings indicate areas of deficiency. Under these circumstances, the Quality Management staff will provide guidance and assistance to providers in making improvements around these identified areas. 106 In monitoring the performance of Providers in its network, CoastalCare utilizes a performance review system which targets specific quality initiatives for provider performance. It is based on these quality initiatives, providers are ranked by their performance into categories: Gold Star, Exceptional, Preferred and Routine. CoastalCare will also monitor the providers with a system that is Core Performance Based according to their contract. Monitoring of Incidents Providers of licensed mental health services and providers of periodic or community based services are required to report incidents to the MCO in the State’s Incident Response Improvement Systems (IRIS). IRIS is the web-based electronic incident reporting system for reporting incidents involving consumers of mental health, developmental disabilities and/or substance abuse services. Providers must submit all Level II and Level III incident reports in IRIS and a summary of all Level I incidents must be submitted to CoastalCare quarterly by the 10th of the month following the end of the quarter. Information on Incidents In: Is Due: First Quarter (July- September) October 10th Second Quarter (October – December) January 10th Third Quarter (January – March) April 10th Fourth Quarter (April- June) July 10th Providers are required to develop and maintain a system to collect documentation on any incident that occurs in relation to a consumer. As part of its quality management process, it is important for the provider to implement procedures that ensure the review, investigation and follow up for each incident that occurs through its own internal Quality Management process. This includes: A review of all incidents on an ongoing basis to monitor for trends and patterns Strategies aimed at the reduction/elimination of trends/patterns Documentation of the efforts at improvement as well as an evaluation of ongoing progress Mandatory reporting requirements are followed Enter Level II and III incidents IRIS There are specific state laws governing the reporting of abuse, neglect or exploitation of consumers. It is important that the provider’s procedures include all of these requirements. If a report alleges the involvement of a provider’s staff in an incident of abuse, neglect or exploitation, the provider must ensure that consumers’ are protected from involvement with 107 that staff person until the allegation is provided or disproved. The agency must take action to correct the situation if the report of abuse, neglect or exploitation is substantiated Incident Reporting Providers of licensed mental health services – meaning the provider and/or facility has a license issued by the Division of Health Services Regulation – and providers of periodic services are required to complete and report incidents to CoastalCare. Private independent practitioners and clinician and hospitals are not required to report. These reports should not be filed in the consumer record, but should be filed on site for review during local monitoring. The state defines incidents as an event at a facility or in a service that is likely to lead to adverse effects upon a consumer. Incidents are classified into three (3) categories, Level I, II, and III, according to the severity of the incident: Level I Incidents: These incidents are those that do not threaten the health and safety of the consumer or others, and require routine care. Level I incidents should be reported to the case manager or clinician involved in the care of the consumer, but do not need to be reported to the Home and Host LME/MCO. It is required that they be documented and filed on site, these reports will be reviewed during local monitoring visit. These reports should not be filed in the consumer record, but should be filed on site for review during local monitoring. Providers are required to submit to CoastalCare the Level I Incident Quarterly Review Report Form. This form can be obtained on the Division website or on this Agency’s website as well. The reports are due in January, April, July, and October. Reports are due to Brandy Wilson at [email protected] the 10th of the month following the end of the quarter. Level II Incidents: These incidents are those that are “any happening, which is not consistent with the routine operation of a facility or service or the routine care of a consumer that is likely to lead to adverse effects upon the consumer.” These reports are to be entered into the IRIS website within 72 hours of the incident. These incidents should also be reported to the case manager and clinician involved in the care of the consumer. These reports should not be filed in the consumer record, but should be filed on site for review during local monitoring. Level III Incidents: 108 These incidents are those that are “any happening, which is not consistent with the routine operation of a facility or service or the routine care of a consumer, that is likely to lead to adverse effects upon the consumer, and result in: Death, permanent physical impairment or psychological impairment to a consumer; A death, permanent physical impairment or psychological impairment caused by a consumer or A threat to public safety caused by a consumer. For Level III incidents a provider peer review team meeting shall occur within 24 hours of the incident. The peer review shall review the consumer record, gather additional information if needed, and file a report in IRIS concerning the incident and notify any other authorities required by law (DSS, healthcare registry, DJJ, etc). The report needs to be submitted within 24 hours of the incident. These reports should not be filed in the consumer record, but should be filed on site for review during monitoring visits. Additional Reporting to the MCO and DMH/DD/SAS: If an incident is likely to be reported in a newspaper, on television or in other media, or if the consumer is perceived to be a significant danger to or concern to the community, the provider in addition to submitting the report in IRIS, is to verbally report the incident to the Grievance and Incident Specialist at (910) 550-2600 within 24 hours of learning of the incident. Restrictive Interventions: There are two types of restrictive interventions, planned and emergency. Restrictive interventions must be documented in the state IRIS system. Planned interventions If there is a therapeutic need for a consumer to have hands on intervention or other rights’ restrictions as on-going interventions it needs to be included as an addendum to the consumer’s person centered plan. This addendum must be signed by a PhD psychologist or MD in addition to the person centered plan. It is also required to have the provider’s or CoastalCare’s Human Rights Committee and guardian approval prior to implementation. These restrictive intervention plans MUST be submitted to CoastalCare to keep on file. If the consumer has a planned intervention as part of their documented treatment and the consumer is not injured during the intervention then this is considered a Level I incident. Again, 109 it is the expectation that these Level I incidents be reported to the case manager/clinician, and be reported on the Provider Quarterly Level I Report. Emergency Interventions: Emergency interventions are those interventions that are not planned, are not part of the consumers person centered plan and have not been approved for use by a Human Rights Committee. These incidents are considered level II incidents and must be reported within 72 hours of the incident via IRIS. Where to report incidents: Level I quarterly reports should be submitted by the 10th of the month that they are due. These reports can be mailed or faxed to CoastalCare to the attention of the Grievance and Incident Specialist or emailed to [email protected] the 10th of the month following the end of the quarter. Level II incident reports are submitted into IRIS within 72 hours of the incident; https://iris.dhhs.state.nc.us All Level III incident reports need to be submitted in IRIS at: https://iris.dhhs.state.nc.us and notification must be given to CoastalCare within 24 hours of the event. All Incident and Death Reporting system information, IRIS information and manuals can be found on the Division of MH/DD./SAS website: http://www.ncdhhs.gov/mhddsas/providers/NCincidentresponse/index.htm Incident Review Process CoastalCare Quality Management Staff shall review all incidents when received by CoastalCare for completeness, appropriateness of interventions, achievement of short and long term follow up both for the individual consumer, as well as the Provider’s service system. If questions/concerns are noted when reviewing the incident report the Quality Management Coordinator will work with the Provider to resolve any identified issues/concerns. If issues/concerns are raised related to consumer care or services or the Provider’s response to an incident, the Quality Management Department may elect to conduct an investigation and/or an onsite review of the Provider. If at all possible the review will be coordinated with the Provider and, if deficiencies are found, the Quality Management and Network Management Departments will work with the Provider on the implementation of a Plan of Correction (POC). 110 It is strongly encouraged that each provider read the instructions manual for further information and clarification. CoastalCare will provide training as needed and when changes are made by the Division of MH/DD/SAS. The Incident and Death Response Systems Manual and IRIS Manual can be found at NC MH/DD/SAS: Manuals and Forms. IRIS website locations: http://www.ncdhhs.gov/mhddsas/providers/NCincidentresponse/index.htm https://iris.dhhs.state.nc.us Test and training site: https://irisuat.dhhs.state.nc.us/ Monitoring to Ensure Quality of Care The Quality Management Department reviews incidents reported and determines whether any follow up is needed. The Quality Management Department may conduct investigations of incidents reported directly by Providers on Incident Reports, as well as reports provided by consumers, families and the community. Grievances The provider must have a Grievance Process to address any concerns of the consumer and the consumer’s family related to the services provided. Providers must keep documentation on all grievances received including date received, points of grievances, and resolution information. Any unresolved concerns or grievances should be referred to the Grievance and Incident Specialist within the Quality Management Department. The Grievance Process must be provided to all consumers and families of consumers’ upon admission and upon request. The provider must advise consumers’ and families that they may contact CoastalCare directly about any concerns or grievances. CoastalCare’s Customer Services Line 1-855-250-1539 must be published and made available to all consumer’s and family members. Additionally, other agencies available to take grievances/complaints must be posted. These agencies include the Division of MH/DD/SA Consumer Care Line in Raleigh toll-free at 800-662-7030 or Disability Rights NC toll-free at 877-235-4210. 111 CoastalCare may receive grievances from providers, stakeholders, consumers, families, legal guardians, or anonymous sources regarding CoastalCare’s Provider Network, and/or a specific provider’s services or provider staff. Based on the nature of the grievance, CoastalCare’s Quality Management Department may choose to form an internal, cross departmental investigative team to investigate the grievance in order to determine its validity. Investigations may be announced or unannounced. It is very important that the provider cooperate fully with all investigative requests. It is important to understand that this is a serious responsibility that is invested in CoastalCare, and that we must take all grievances very seriously until we are able to resolve them. CoastalCare’s management of grievances is carefully monitored by the Division of Medical Assistance (DMA) and the Division of MH/DD/SAS (DMH). Additionally, CoastalCare maintains a database where all grievances and resolutions are recorded for tracking and trending. CoastalCare’s Quality Management Department maintains documentation on all follow up and findings of any grievance investigation and a written summary will be provided to the provider. If issues are identified, CoastalCare may be required to refer the matter to other regulatory agencies, such as Division of Medical Assistance, Division of MH/DD/SAS or Division of Health Service Regulation, for further investigation and/or the provider involved may be required to complete a Plan of Correction (POC). Additionally, Human Rights Committee (HRC) has a responsibility to oversee CoastalCare compliance with federal and state rules regarding consumer rights, confidentiality, and grievances. The CoastalCare HRC is made up of consumers, family members and expert advisors who meet at least quarterly. The CoastalCare HRC reviews and monitors all trends in the use of restrictive interventions, abuse, neglect and exploitation, deaths and medication errors. The HRC also makes reports to the CoastalCare Board of Directors and DMA/DMH The HRC reviews grievances regarding services as an advisor to the Area Director/CEO Consumers or family members of the consumers that wish to apply to serve on the HRC may call the CoastalCare Quality Management Department at # (910) 550-2661. Perception of Care Surveys The Perception of Care survey is administered to a random selection of consumers each year. CoastalCare will provide the agencies that are selected to participate with the forms. Providers are required to provide them to the selected consumers and return the completed forms to CoastalCare. Providers will be informed of the timelines for submission. CoastalCare values the satisfaction of consumers, family members, stakeholders with service provided in the CoastalCare network. CoastalCare has various ways consumers’ satisfaction is 112 measured. These include annual surveys. The goal of these initiatives is to gather feedback on how various CoastalCare departments perform during random and anonymous monitoring. This system has provided excellent information that has been used to pinpoint the need for additional training of staff Medical Record Requirements/Service Record Standards The requirements ensure that the Network Provider complies with state and federal laws and rules for service records, confidentiality, and records retention so that service record standards are met. The Providers of services shall maintain a Service Record for each individual served in accordance with Service Records standards set forth by state or federal law, the DMH/DD/SAS Division regulations and/or DHHS policy. The original Service Record related to services provided shall be accessible for review for the purpose of monitoring services rendered. Service Records shall be retained for the duration and the format according to the LME/MCO policies, State and Federal Law, and in accordance with the APSM 10-3, Records Retention and Disposition Schedule for State and Area Facilities. If for any reason the Provider can no longer maintain the Service Record, the Provider must contact the LME/MCO Medical Records Specialist, Marianne de la Vega at 910-459-4860 or [email protected] for further instructions on how to handle the Service Records. Providers are required to adhere to the APSM 45-2, Records Management and Documentation Manual for Providers of Publicly-Funded MH/DD/SA Services, CAP-MR/DD Services and Local Management Entities, the APSM 45-1, Confidentiality Rules for Mental Health, Developmental Disabilities and Substance Abuse Services, the APSM 10-3, Records Retention and Disposition Schedule for State and Area Facilities, and the APSM 30-1, Rules For MH/DD/SA Facilities and Services. When a provider is found to be out of compliance through a complaint or any other communication regarding any service record standards and/or confidentiality rules and laws, a follow-up process will be reported and take place. State Level Requirements Documents APSM 30-1 Rules For MH/DD/SA Facilities and Services APSM 45-1 Confidentiality Rules For MH/DD/SA Services 113 APSM 45-2 Records Management and Documentation Manual APSM 10-3 Records Retention and Disposition Schedule GS 122 C Mental Health, Substance Abuse, Developmental Disabilities Act of 1985 GS 122C-52 Right to Confidentiality Federal Level Requirements Documents 42 CFR Part 2 Confidentiality Regulation – Substance Abuse Information 45 CFR Part 160 Standards for Privacy of Health Information and 164 Corporate Compliance Corporate Compliance Program CoastalCare is committed to upholding the highest level of professional and business standards within the provider network. Providers are expected to maintain and promote a culture of ethical practice in all aspects of business operations. Providers are expected to have a mechanism to ensure compliance with laws, rules and regulations. Providers will conduct activities to prevent, detect and correct fraud, waste and abuse. Providers of Medicaid services are required to implement a corporate compliance program as required under federal law. Primary Areas: Corporate Compliance is responsible for establishing a centralized mechanism to track and ensure compliance with all applicable state and federal laws, accreditation standards, rules and regulations. CorporateCompliance conducts activities to prevent, detect, report and investigate suspected fraud and abuse. The Compliance Program is intended to provide reasonable assurance that CoastalCare: Complies with applicable federal, state and local laws, rules and regulations; Satisfies the compliance requirements outlined in the contract with the North Carolina Department of Health and Human Services; Prevents, detects, and reports known or suspected fraud and abuse or other forms of misconduct that might expose this agency to significant criminal or civil liability; 114 Promotes self-auditing and self-policing, and provides for voluntary disclosure of violations of laws, rules or regulations; Establishes, monitors, and enforces high professional and ethical standards. Providers must monitor for potential fraud and abuse and take immediate action to address reports or suspicion. According to 42 CFR Part 455- Program Integrity: Medicaid, The term “fraud” is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.The term “abuse” is defined as provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. Corporate Compliance Plan CoastalCare has a Corporate Compliance Plan to guard against and identify fraud and abuse. The Plan describes the Corporate Compliance Program, sets the tone for the compliance culture, reflects Compliance policies, and provides guidance to staff on the Code of Conduct and specific applicable regulatory requirements including fraud, waste and abuse. The objective of the Plan is to prevent, detect and correct violations of laws, rules, regulations and the Code of Conduct. Providers of Medicaid services are required to implement a corporate compliance program as required under federal law. An effective Corporate Compliance Plan should include seven basic guidelines according to the U.S. Sentencing Guidelines: 1. 2. 3. 4. 5. 6. 7. Written policies and procedures, A designated compliance officer and a compliance committee, Effective training and education, Effective lines of communication, Standards enforced through well-publicized disciplinary guidelines, Auditing and monitoring, and Responses to detected offenses and corrective action plans. Compliance Committee CoastalCare has a formal Corporate Compliance Committee that oversees the Corporate Compliance Program. The Corporate Compliance Committee is a standing subcommittee of the agency’s Quality Management Committee. The Committee conducts an annual compliance 115 audit. The Corporate Compliance Committee annually evaluates the effectiveness of the Plan and makes revisions as needed. ComplianceHelp Desk CoastalCare has a designated Compliance Help Desk that is monitored by the Corporate Compliance Department. Providers can submit questions and seek guidance on compliance by contacting [email protected]. A response will be given within one business day. Compliance Reporting Tools CoastalCare has initiated EthicsPoint, a secure and confidential tool to report matters involving compliance, ethics, fraud, and abuse. Reports can be made online or by calling the telephone tip line. EthicsPoint is available 24 hours a day, 7 days a week. The hotline is confidential and CoastalCare will honor this anonymity in full compliance with the standards. Reports will be sent to, acted upon and monitored by the Corporate Compliance Department. The Corporate Compliance Department will forward all credible allegations of fraud along with supporting documentation to DMA Program Integrity. To make a report: Go to: https://secure.ethicspoint.com/domain/en/report_custom.asp?clientid=34587 OR Call toll-free: 1.855.659.7660 Monitoring and Auditing CoastalCare conducts internal data integrity checks, audits and compliance investigations. CoastalCare has adopted a fully operational set of processes that proactively protects the agency and detects fraud and abuse, which contains both internal and external components. Investigation and Reporting When CoastalCare receives information regarding an alleged compliance violation, an investigation will occur to collect information and determine the validity. The Corporate Compliance Department will forward all credible allegations of compliance issues and fraud, waste or abuse along with supporting documentation to the appropriate regulatory bodies. Code of Ethics CoastalCare has established a Code of Ethics to promote lawful and ethical behavior by all employees, area board members, providers and the Consumer and Family Advisory Committee 116 (CFAC) and to ensure that CoastalCare’s business is conducted according to the established CoastalCare values as well as all applicable rules, regulations and laws. False Claims Act Education Requirements& Affordable Care Act Section 6023 of the Deficit Reduction Act (DRA) of 2005 requires providers receiving annual Medicaid payments of $5 million or more to educate employees, contractors, and agents about Federal and State fraud and false claims laws and the whistleblower protections available under those laws. For more information visit the North Carolina Division of Medical Assistance website at: http://www.ncdhhs.gov/dma/fca/index.htm. Additionally, the Affordable Care Act and Sessions Law 2011-399, modified this requirement. The federal rule 455.23 enacted requires ALL Medicaid providers, regardless of the amount reimbursed, to attest that they met the minimum business requirements necessary to comply with all federal and state requirements.For more information visit the federal government website of healthcare.gov at: http://www.healthcare.gov/law/full/index.html Dispute Resolution Process for Providers Dispute Resolution is the formal mechanism available to all participating providers to have a CoastalCare decision to levy sanctions reviewed and/or reconsidered, upon provider request. The appeal is reviewed by a panel not involved in the original decision. For violation(s) involving professional competence or conduct sanctioning decisions are reviewed by a twolevel panel system of clinical peers and CoastalCare staff. For violation(s) involving administrative matters, decisions to levy sanctions are reviewed by a designated CoastalCare staff member. The dispute resolution mechanism is not available for contractual violations. Any participating provider may avail themselves of the dispute resolution process, unless the sanction is classified as undisputable, i.e. involving explicit requirements of the written agreement, such as maintenance of licensure, insurance coverage or if the provider is convicted of claims fraud. Role and Responsibilities of the Network Management Department The CoastalCare Network Management Department will review documentation regarding provider audits and investigations. Upon a review of documentation, the Network Management Department will make recommendations regarding: o Sanctions and penalties o Disenrollment from the Network 117 o Lifting of a freeze on referrals or sanction o The need for additional provider technical assistance or training o Referral to the Credentialing Committee CoastalCare shall determine sanctions or penalties to be implemented. Such sanctions may include, but are not limited to: o A corrective action plan. o o o o o Suspension of referrals. Transfer of CoastalCare funded clients to another provider. Additional monitoring activities De-credentialing of individual practitioners within the agency. De-credentialing for the provider agency. The Network Management Department shall notify the providers of any sanctions levied. Role and Responsibility of the First and Second Level Peer Review Panels For professional competence or conduct violations, the 1st level dispute panel will include at least three qualified individuals, at least one of which must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider who filed the dispute. Within 5 business days of receipt of the Dispute Resolution Request form, the Network Management Director will select qualified members for the first level panel. The panel convenes within 10 business days of the selection of all qualified members. The three members review all available documentation as a group and deliberate until a consensus is reached. The review panel will make a determination and document whether the original sanction decision is appropriate and whether the agency followed the procedure correctly. The Network Management liaison responds in writing to the provider initiating the dispute within 5 business days. A decision letter will be sent via certified mail and outlines the final step in the agency’s dispute resolution process. If the provider disagrees with the decision and wishes to continue the dispute; a request must be sent in writing to CoastalCare Network Management department within 10 days of receipt of the level 1 dispute decision letter. Additional information may be included for consideration along with the second level dispute request. (See requirements below.) 118 Within 5 business days of receipt of the second-level dispute request, the liaison documents the request in the providers’ file and forwards the packet to the Network Management Director or designee. The Network Management Director selects qualified members for a second level dispute panel within 10 business days. This panel includes; at least three qualified individuals of whom one of which must be a participating provider who is not otherwise involved in any previous decisions and who is a clinical peer of the participating provider that has filed the dispute. These three individuals must not have been involved in the first level panel or original decision. The panel convenes within 10 business days of the selection of all qualified members. The three members review all available documentation as a group and deliberate until a 2:1 consensus is reached. The review panel will make a determination and document whether the original sanction decision is appropriate and whether the agency followed the procedure correctly. The panel documents the decision using the Dispute Resolution Determination form within 2 business days. The provider is notified of the determination by certified mail within 5 business days of the review. The second level review panel decision is documented in the providers’ file. The letter will include contact information in the event the provider wishes to pursue a State level appeal/dispute. Role and Responsibilities of the Credentialing Committee The Credentialing Committee may change a provider’s credentialing status (i.e. suspension or revocation) on the basis of an action or non-action that is found to violate CoastalCare’s standards of practice. The Credentialing Committee will make reports to the licensing boards for independent licensed practitioners and based on audit findings. Role and Responsibility of the Finance Department The Finance Department may pursue a variety of options to enforce the payback, including withholding of future claims payments, invoicing and collecting from the provider, or referring the assessment to a third party collection agency. Collection efforts may include initiating legal action and obtaining a judgment and execution of the judgment against the provider for the payback. The Finance Department also has responsibility to assess provider paybacks arising from Coordination of Benefits (COB) and Sliding Fee Scale audits. Paybacks Due and Payable upon Completion of the Dispute Resolution Process All paybacks are due and payable by the Provider upon completion of the reconsideration. All reimbursement to the provider shall cease unless and until the required payback is paid in 119 full. Paybacks shall be paid by withholding reimbursement payments due to the Provider or by direct repayment to CoastalCare, as specified in an approved payment plan. All payments due to the Provider shall continue to be withheld until either the payback is paid in full or a payback payment plan is approved in writing. State Appeal Process In accordance with General Statute 122C-151.4, if the Provider is not satisfied with the final CoastalCare decision involving State funded services, the Provider may file an appeal of the final CoastalCare decision with the State Mental Health/Developmental Disabilities/Substance Abuse ("MH/DD/SA") Appeals Panel as outlined below at the following address: Division Director/Appeals Panel N.C. Division of MH/DD/SAS 3001 Mail Service Center Raleigh, NC 27699-3001 1. General Statute 122C – 151.4 subsections c (1), (2), (3) provides Consumers, Contractors and former Contractors the right to file Appeals to the State MH/DD/SA Appeals Panel after they have exhausted the appeals (Provider Reconsideration or Consumer Grievance) process at CoastalCare. a. A contractor or former contractor who claims that an area authority or county program is not acting or has not acted within applicable State law or rules in imposing a particular requirement on the contractor on fulfillment of the contract; b. A contractor or former contractor who claims that a requirement of the contract substantially compromises the ability of the contractor to fulfill the contract; c. A contractor or former contractor who claims that an area authority or county program has acted arbitrarily and capriciously in reducing funding for the type of services provided or formerly provided by the contractor or former contractor. 2. A Provider wishing to appeal the final CoastalCare decision can file an appeal with the State MH/DD/SA Appeals Panel as follows: a. The Provider shall file written notice of appeal with the Director of the Division of MH/DD/SAS at the address provided above within fifteen (15) calendar days of the date of the final PBH decision. 10A N.C.A.C. 27G.0810 120 b. File or filing means personal delivery, delivery by certified mail, or delivery by overnight express mail to the current Director of the N.C. Division of MH/DD/SAS. A document is deemed filed as of the date of delivery to the Director. Failure to timely file or to file in conformity with the rules shall be considered an improper filing and denied. 10A N.C.A.C. 27G.0810 (b). c. The Division Director will appoint an impartial Panel (the "Panel") to complete an administrative review and make an administrative review decision on the appeal. 10A N.C.A.C. 27G.0810 (e)-(l). i. The administrative review decision is appealable by either the Provider or CoastalCare upon written request for an informal hearing made to the Chairman of the Panel within 15 business days of the date of the administrative review decision. 10A N.C.A.C. 27G.0810 (m). ii. If no appeal is made with 15 business days of the date of the administrative review decision, the administrative review decision shall be considered final. 10A N.C.A.C. 27G.0810 (n). d. The administrative code at 10A N.C.A.C. 27G.0811 provides the process and procedures for an informal hearing. The Panel will render a hearing decision, which may be appealed pursuant to N.C. Gen. Stat. § 122C-151.4(f), as set forth below. e. The final CoastalCare decision, including the requirement for a payback, is not stayed by an appeal to the Panel. N.C. Gen. Stat. § 122C-151.4(d), f. Chapter 150B Appeal: In accordance with N.C. Gen. Stat. § 122C-151.4(f), a Provider that is dissatisfied with the Panel's hearing decision may file a contested case under Chapter 150B of the North Carolina General Statutes. Notwithstanding G.S. 150B-2(1a), CoastalCare as an area authority is considered an agency for purposes of the limited appeal authorized by this section. The Secretary shall make a final decision in the contested case. Definitions Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. (Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care, October 2000) 121 Action: An action is defined as an event in which CoastalCare applies sanctions such as the requirement for a Plan of Correction, payback, or referral freeze. The action is the result of findings from audits, quality of services evaluations, investigations, or report by outside investigative authorities. An action also includes a denial (in whole or in part) of a provider’s request to employ a family member to serve a consumer. Fraud: A deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care, October 2000) Reconsideration Committee: The Reconsideration Committee and its Chair are appointed by the Area Director. The Committee has authority to make final determinations on provider Requests for Reconsideration of CoastalCare Actions. Reconsideration Review: A review of an action based on the Provider’s Reconsideration Request and any additional materials presented by the Provider. This process includes a review of the decisions of the first and second level peer review. The Reconsideration Committee makes the final determination as to whether the Provider’s request is approved or denied by CoastalCare. 122 Glossary of Terms Definitions included in this section are primarily for clarification of terms used in this manual or references. However many of these definitions are also used in existing state and Area Authority documents and are included here to be helpful but are not to be considered comprehensive. Where similar definitions apply to multiple terms, the terms are grouped. Broad categories are defined with specific elements detailed as a part of the entire definition. ACCESS – An array of treatments, services and supports is available; consumers know how and where to obtain them; and there are no system barriers or obstacles to getting what they need, when they are needed. ACCREDITATION – Certification by an approved national accrediting organization that has a set of standards. This is a requirement of select service definitions. ACTT - Assertive Community Treatment Team – enhanced Medicaid service ADULT - A person 18 years of age or older, unless the term is given a different definition by statute, rule, or policies. ADMINISTRATIVE SERVICES - Services other than the direct provision of MH/DD/SA services (including case management) to eligible or enrolled persons, necessary to manage the MH/DD/SA system, including but not limited to: Provider Services and contracting, provider billing accounting, information technology services, processing and investigating grievances and appeals, legal services (including any legal representative of the Contractor at Administrative hearings concerning the Contractors decisions and actions), planning, program development, program evaluation, personnel management, staff development and training, provider auditing and monitoring, utilization review and quality management. ADVOCACY – Activities in support of, or on behalf of, people with mental illness, developmental disabilities or addiction disorders including protection of rights, legal and other service assistance, and system or policy changes. AMERICAN SOCIETY OF ADDICTION MEDICINE (ASAM) - An international organization of physicians dedicated to improving the treatment of people with substance use disorders by educating physicians and medical students, promoting research and prevention, and informing the medical community and the public about issues related to substance use. In 1991, ASAM published a set of patient placement criteria that have been widely used and analyzed in the alcohol, tobacco and other drug field. AOC - Administrative Office of the Courts 123 APPEAL- means a formal request for review of a decision made by the Contractor or a subcontracted provider related to eligibility for covered services or the appropriateness of treatment services provided. APPEALS PANEL - The State MH/DD/SA appeals panel established under NC. G.S.371 AREA AUTHORITY –Local oversight agency of MH/DD/SA services, formerly known as LME ASSERTIVE ENGAGEMENT – A service offered though CoastalCare’s Benefit Plan. The service uses an alternative service definition. Assertive Engagement is designed to assist new consumers with engaging in treatment. This service is available to all disability areas. ASSESSMENT – A comprehensive examination and evaluation of a person’s needs for psychiatric, developmental disability or substance abuse treatment, services and/or supports according to applicable requirements. AUTHORIZATION - The process by which Utilization Management agrees to a medically necessary specific service or plan of care based upon best practice. The granted request of a provider is assigned a number for tracking and linked to the subsequent claim that will be made for reimbursement. PRE-AUTHORIZATION/PRIOR AUTHORIZATION is the process of approving use of certain resources in advance rather than after the service has been requested. Approval for admission to hospitals in an emergent situation is one example. RE-AUTHORIZATION is the process of submitting a request for services for a consumer who has already received authorized services. The request shall specify the scope, amount and duration of service requested and shall indicate the consumer’s progress toward outcomes, the use of natural and community supports, and how the requested services will support the outcome the individual is seeking. RETROSPECTIVE AUTHORIZATION is authorization to provide services after the services have been delivered. AVAILABILITY-Within the MH/DD/SA service network, the agency has defined availability as the ability of consumers to receive appropriate care within defined timeframes. An example of an Availability Goal would be having sufficient provider capacity so that consumers can receive a needed routine service within 5 days of initiation. BASIC SERVICES – Mental health, developmental disability or substance abuse services that are available to North Carolina residents who need them whether or not they meet criteria for target or priority populations. BENEFIT PACKAGE OR PLAN – An array of treatments, services and/or supports intended to meet the needs of target or priority populations. BENEFIT LIMITATIONS are any provision, other than an exclusion, which restricts coverage, regardless of medical necessity. Covered Benefits are medically necessary services that are specifically provided for under the provisions of 124 Evidence of Coverage. A covered benefit shall always be medically necessary, but not every medically necessary service is a covered benefit. For example, some elements of custodial or maintenance care, which are excluded from coverage, may be medically necessary, but are not covered. BEST PRACTICE(S) – Interventions, treatments, services or actions that have been shown by substantial research or professional consensus to generate the best outcomes or results. The terms, EVIDENCE-BASED, or RESEARCH-BASED may also be used. BLOCK GRANT – Funds received from the federal government (or others), in a lump sum, for services specified in an application plan that meet the intent of the block grant purpose. (Also referred to as CATEGORICAL FUNDING) BUSINESS NEEDS OF THE ORGANIZATION - to include the contractual obligations of the agency, state and federal rules and regulations, accreditation standards, access and availability standards and goals, the Network Sufficiency and Development Plan and having an adequate number of choices for consumers within a service, when applicable. CABHA –Critical Assess Behavioral Healthcare Agency CARE COORDINATION – The methods utilized to notify other providers of significant events in the course of care and to enable multiple providers to give integrated care to an individual. Professionals with a broad knowledge of the resources, services and programs supported by the public MH/DD/SA system and the community at-large, advocate for access and link individuals to entitlements and services. It is an administrative Service Management Function performed by the Contractor for individuals not enrolled or not meeting target population definitions. CARF - Council on Accreditation of Rehabilitation Facilities CATCHMENT AREA - The geographic part of the State served by a specific Contractor. The GEOGRAPHIC AREA can be a specific county or defined grouping of counties that are available for contract award. The Contractor is responsible to provide covered services to eligible residents of their area. CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS) - The federal agency responsible for overseeing the Medicaid and Medicare programs. Formerly, it was known as the Health Care Financing Administration, (HCFA). CERTIFICATION – A Statement of approval granted by a certifying agency confirming that the program/service/agency has met the standards set by the certifying agency. The Contractor or the NC Council may be the certifying agency for subcontracted Providers. 125 CERTIFIED MAIL –mail with proof of delivery CFAC – Each LME has a Consumer Family Advisory Committee which is comprised of consumers and family members representing all disability groups. CFACs meet on a regular basis in their communities to support and communicate their concerns and provide advice and comment on all state and local plans. CHILD - Eligible person who is under the age of I8 unless the term is given a different definition by statute, rule or policies CLAIMS MANAGEMENT – The process of receiving, reviewing, adjudicating, INVESTIGATING, paying, and otherwise processing service claims submitted by network and facility providers. CLAIM – An itemized Statement of services, performed by a provider network member or facility, which is submitted for payment. CLEAN CLAIM- means a claim that successfully passes all adjudication edits. CLIENT - An individual who is admitted to or receiving public services. “Client” includes the client’s personal representative or designee and the terms CONSUMER, RECIPIENT and PATIENT are often used interchangeably. CLIENTOUTCOMES INVENTORY (COI) – DMH/DD/SAS measurement system for assessing treatment/services outcomes of mental health and substance abuse service consumers. CLIENT DATA WAREHOUSE - The DHHS’s source of information to monitor program, clinical and demographic information on the clients served. The data are also used to respond to Departmental, Legislative and Federal reporting requirements. CLINICAL HOME– Treatment provider that is responsible for writing the Person Centered Plan CLINICAL PRACTICE GUIDELINES – Utilization and quality management mechanisms designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case. The guidelines or TREATMENT PROTOCOLS are summaries of best practice research and consensus. They include professional standards for providing care based on diagnostically related groups. NC has adopted protocols for MH and DD. NC uses ASAM Guidelines for substance abuse. COA - Council on Accreditation CO-MORBID CONDITION, CO-OCCURRING DISORDERS, DUAL DIAGNOSIS –Terms that reflect the presence of two or more disorders at the same time (e.g. Substance abuse and mental illness; developmental disability and mental illness; substance abuse and physical health conditions, etc) and require specialized approaches. 126 COMPLAINT – A report of dissatisfaction with some aspect of the public MH/DD/SA system. The term DISPUTE is used to indicate a specific complaint about a service or a provider that requires attention and joint resolution. COMPREHENSIVE CLINICAL ASSESSMENT (CCA) -- An intensive clinical and functional face-toface evaluation by a Licensed Professional of an individual’s presenting mental health, developmental disability, and/or substance abuse condition that results in the issuance of a written report, providing the clinical basis for the development of a Person-Centered Plan [PCP] and recommendations for services/supports/treatment. CONFLICT OF INTEREST – A situation where self interest could negatively impact the best interests of the person being served or the system CONSENSUS - Majority opinion regarding a group decision. It is not the same as total agreement. CONSUMER - An individual who is admitted to or receiving public services. “Consumer” includes the consumer’s personal representative or designee and the terms CLIENT, RECIPIENT and PATIENT are often used interchangeably. CONSUMER/FAMILY ADVISORY COMMITTEE – A Board appointed group of persons receiving services, families of persons receiving services, advocates and other stakeholders that participate in meaningful decision making relative to the local program. The group shall meet at least monthly in a public forum to review data, practices, policies and plans of the Contractor and make recommendations to the Board from the consumer/family perspective. CONTRACT- A legal agreement between a payer and a subscribing group or individual which specifies rates, performance covenants, the relationship among the parties, schedule of benefits and other pertinent conditions. The contract usually is time limited. A contract is defined as a document that governs the behavior of a willing buyer and a willing provider. In this case the Contract is the 2004 Performance Agreement between the Department and the LME. CONTRACTOR- An organization or entity agreeing by signature to provide the goods and services in conformance with the stated contract requirements, NC statute and rules and federal law and regulations CONTRACT YEAR - A period from July I of a calendar year through and including June 30 of the following year COPAYMENT- The portion of the cost of services which the enrolled person pays directly to the Contractor or the subcontracted providers at the time-covered services are rendered 127 CORE SERVICES – BASIC SERVICES such as screening, assessment, crisis or emergency services available to any person who needs them whether or not they are a member of a target or priority population. The term also includes universal services such as education, consultation and prevention activities intended to increase knowledge about mental illness, addiction disorders, or developmental disabilities, reduce stigma associated with them and/or prevent avoidable disorders. CORPORATE COMPLIANCE – The systematic local governance plan for detection of fraud and abuse as defined in the Balanced Budget Act. CREDENTIALING – The process of approving providers for membership in a network to provide services to consumers. This term can also refer to a peer competency-based credential such as a license for professionals. CRISIS – Response to internal or external stressors and stressful life events that may seriously interfere with compromise a person’s ability to manage. A crisis may be emotional, physical, or situational in nature. The crisis is the perception of and response to the situation, not the situation itself. CRISIS RESPONSE is the immediate action to assess for acute MH/DD/SA service needs, to assist with acute symptom reduction, and to ensure that the person in crisis safely transitions to appropriate services. These services are available 24 hours per day, 365 days per year. These services may be referred to as EMERGENCY services as well. NC requires a CRISIS PLAN for consumers to promote recovery and to lessen the trauma of emergency events. CULTURAL COMPETENCE/PROFICIENCY – A process that promotes development of skills, beliefs, attitudes, habits, behaviors and policies which enable individuals and groups to interact appropriately, showing that we accept and value others even when we may disagree with them. CUSTOMER – Customers may be ULTIMATE CUSTOMERS who are the intended and actual recipients of the services provided by the public system, INTERNAL CUSTOMERS are those individuals internal to the system who rely on each other to provide the service to the ultimate customer; and EXTERNAL CUSTOMERS are those groups and individuals outside the system that have a stake in the outcomes and products produced by the system. The concept is critical to proper implementation of DD –SEE IDD DEFAULT – The breach of conditions agreed to in this Contract and/or failure tom perform based upon defined terms and conditions the scope of work specified in the Contract. DE-INSTITUTIONALIZATION – Release of people from institutions to care, treatment and supports in local communities. De-institutionalization became national policy with the Community Mental Health Centers Act of 1963. The 1997 Supreme Court decision in OLMSTEAD 128 V. LC has given new momentum to development of community based services for individuals who have remained in State hospitals and mental retardation centers because community services were not available. This movement is often referenced as movement to least restrictive care or to lower levels of care where safety and community integration are balanced and supported through the community system of services. DEMOGRAPHIC DATA SUBMISSION – submission of demographic data of SEC consumers through the Alpha provider portal DEPARTMENT OF HEALTH AND HUMAN SERVICES, (DHHS) – North Carolina agency that oversees State government human services programs and activities. DEVELOPMENTAL DISABILITY - A severe, chronic disability of a person which: a) is attributable to a mental or physical impairment or combination of mental and physical impairments; b) is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22; c) is likely to continue indefinitely and, d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction and economic self sufficiency; and e) reflects the person’s need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of a lifelong or extended duration and are individually planned and coordinated; or f. when applied to children from birth through four years of age, may be evidenced as a developmental delay. DHHS - Department of Health and Human Services. DIAGNOSTIC AND STATISTICAL MANUAL (DSM IV) – A book published by the American Psychiatric Association, of special codes that identify and describe MH/DD/SA disorders DISASTER – A disaster is any natural or human-caused event, which threatens or causes injuries, fatalities, widespread destruction, distress, and economic loss. Disasters result in situations that call for a coordinated, multi-agency response. A disaster calls for a response and resources that usually exceed local capabilities DIVERSION – Choosing lower cost and/or less restrictive services and/or supports. An example would be choosing a community program instead of sending a person to a State hospital. The term is also used when preventing arrest or imprisonment by providing services that restore functioning and avoid detention. In North Carolina diversion programs are in place in response to SB859 that prohibits admission of persons with mental retardation to public psychiatric hospitals. DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES (DMH/DD/SAS) - A division of the State of North Carolina, Department of Health and 129 Human Services responsible for administering and overseeing public mental health, developmental disabilities and substance abuse programs and services. DJJDP - Department Of Juvenile Justice and Delinquency Prevention DOMAINS - Major areas of concern to the NC public MH/DD/SA system and its mission, goals, and strategies and for which indicators and measures are developed to examine outcomes of service in the lives of people served. DPI - Department of Public Instruction DSS - Department of Social Services EARLY PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) – Early and Periodic Screening, Diagnosis and Treatment is a Medicaid program for Title XIX individuals under the age of 21. This mandatory preventive child health program for Title XIX children requires that any medically necessary health care service identified in a screening be provided to an EPSDT recipient. The MH/DD/SA component of the EPSDT diagnostic and treatment services for Title XIX members under age 21 years are covered by this contract. EDUCATION – Activities designed to increase awareness or knowledge about any and all aspects of mental health, mental illness, developmental disability or substance abuse to individuals and/or groups. Education and training are also activities or programs delivered to staff to ensure that service providers are competent to provide services identified as best practices. ELIGIBILITY – Determination of the service and/or benefit package an individual may be entitled to or determination of a class membership that allows entry to certain services and supports. The determination that individuals meet prescribed criteria for a particular program, set of services or benefits. EARLY INTERVENTION - The provision of psychological help to victims/survivors within the first month after a critical incident, traumatic event, emergency, or disaster aimed at reducing the severity or duration or event-related distress. For mental health service providers, this may involve psychological first aid, needs assessment, consultation, fostering resilience and natural supports, and triage, as well as psychological and medical treatment. EMERGENCY- Means a situation in which an individual is experiencing a serious mental illness or a developmental disability, or a child is experiencing a serious emotional disturbance, and one of the following apply: o The individual can reasonably be expected within the near future to physically injure himself, herself, or another individual, either intentionally or unintentionally o The individual is unable to provide himself or herself food, clothing, or shelter, or to attend to basic physical activities such as eating, toileting, bathing, grooming, dressing or ambulating, and this inability may lead in the near future to harm to the individual or to another individual. o 130 The individual’s judgment is so impaired that he or she is unable to understand the need for treatment and, in the opinion of the mental health professional, his or her continued behavior as a result of the mental illness, developmental disability, or emotional disturbance can reasonably be expected in the near future to result in physical harm to the individual or to another individual. ENHANCED BENEFITS –Services listed in the Medicaid Clinical Coverage Policy 8A. ENROLLED – Individuals are admitted for service and have been provided at least one service and assigned a unique identifying number. FAIR HEARING RIGHTS – Advance and Adequate Notice - The notice to the Contractor in accordance with DHHS policy and procedure using prescribed forms when denying, reducing, suspending or terminating covered services that require prior authorization. The Contractor shall comply with all notice, appeal and continuation of benefits requirements specified by State and federal law and regulations. FEE FOR SERVICE – A method of payment for health care. A payer pays the Contractor or a service provider for each reimbursable treatment, upon submission of a valid claim, and according to agreed upon business rules. The FEE SCHEDULE is a list of reimbursable services and the rate paid for each service provided. FEM – Frequency and Extent of Monitoring FEMA - Federal Emergency Management Agency FORENSIC – Term used to describe a person with mental illness, developmental disability or substance abuse who is involved in the criminal justice system. This includes persons found Not Guilty by Reason of Insanity (NGRI), those who are Incompetent to Stand Trial, or who are in jails or prisons or referred to the mental health system by criminal courts for evaluation and treatment. FORM B – see Demographic Data Submission FORMULARY – Lists of drugs that are considered preferred therapy for a given condition and cost effective and are to be used by providers in prescribing medications. FUNCTIONAL OUTCOMES - The extent to which individuals receiving services and supports reach their goals. These outcomes generate from DOMAINS as defined earlier related to desirable life developments that all people wish to achieve, such as safe and affordable housing, employment or a means of support, meaningful relationships, participation in the life of the community, etc. GAPCD - Governor’s Advisory Council for Persons with Disabilities GENERAL FUND – State funds used by the General Assembly for public programs and initiatives. 131 GEOGRAPHIC ACCESSIBILITY – A measure of access to services, which is generally determined by drive/travel time or number and type of providers in a service area. The Contract standard is 30 minutes/30 miles. GRIEVANCES – A formal complaint by a service recipient that shall be resolved in a specified manner detailed in this Contract. HEALTH CHOICE – The health insurance program for children in North Carolina that provides comprehensive health insurance coverage to uninsured low-income children Financing comes from a mix of federal, State, and other non-appropriated funds. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) –Public Law 104-191, 1996 to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of the Social Security Act, and the efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of standards and requirements for the electronic transmission of certain health information. The Act provides for improved portability of health benefits and enables better defense against abuse and fraud, reduces administrative costs by standardizing format of specific healthcare information to facilitate electronic claims, directly addresses confidentiality and security of patient information - electronic and paper-based, and mandates “best effort” compliance. HIPAA - Health Insurance Portability and Accountability Act HUD - Housing and Urban Development HUMAN RIGHTS COMMITTEE – The body established by statute for hearing grievances and appeals related to rights violations guaranteed by law and under this contract. IDD – Intellectual or Developmental Disability INCURRED BUT NOT REPORTED (IBNR) - means liability for services rendered for which claims have not been received. Refers to claims that reflect services already delivered, but, for whatever reason, have not yet been reimbursed. Failure to account for these potential claims could lead to inaccurate financial estimates. INSURANCE WITHIN MOA INTEGRATED PAYMENT AND REPORTING SYSTEM (IPRS) - An electronic, web-based system for reporting services and making payments that will eventually replace the Willie M., Thomas S., and Pioneer systems of claims processing The IPRS system will be built on the existing Medicaid Management Information System (MMIS) currently processing Medicaid claims for the Division of Medical Assistance, (DMA). The goal of the IPRS project is to replace the existing UCR 132 systems with one integrated system for processing and reporting all MH/DD/SAS and Medicaid claims. JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO) –Agency that reviews the care provided by hospitals and determines whether accreditation is warranted. LEAST RESTRICTIVE CARE – The service that can be provided in the most normative setting while ensuring the safety and well being of the individual LENGTH OF STAY (LOS) – The amount of time that a person remains in a service program, including hospitals, expressed in days. LEVEL OF CARE (LOC) - A structured system for evaluating acuity and INTENSITY OF NEED against the amount, duration and scope of service required by a consumer. For substance abuse programs, as used in the ASAM criteria for substance abuse, this term refers to four broad areas of treatment placement, ranging from inpatient to outpatient. LICENSURE – A State or federal regulatory system for service providers to protect the public health and welfare. Licensure of healthcare professionals and hospitals are examples. LOCAL BUSINESS PLAN – In the reformed MH/DD/SA system, a comprehensive plan of local management entities for mental health, developmental disabilities and substance abuse services in a certain geographical area (See CoastalCare Strategic Plan) LOCAL MANAGING ENTITY (LME) - The local administrative agency that plans, develops, implements, and monitors services within a specified geographic area according to the terms of this Contract including the development of a full range of services and/or supports for both insured and uninsured individuals. LOCAL QUALITY MANAGEMENT COMMITTEE – A cross system group of stakeholders including the LME, providers, consumers, and family members that reviews data and trends to make recommendations for continuous improvement in the system of care and supports. MANAGEMENT REPORTS – Collections of data that are benchmarked to enable the agency to compare performance against standards and to seek continuous improvement. The reports should be comprehensive incorporating timeliness, utilization and penetration rates, customer satisfaction, functional outcomes and compliance with various standards and terms inherent in this Contract. MEDICAID – A jointly funded federal and State program that provides medical expense coverage to low-income individuals, certain elderly people and people with disabilities The Federal government requires that the State/local government match the federal government funds. In North Carolina, this is approximately 60% federal/40% State/local match. People qualifying for Medicaid are “entitled” to supports and services based upon a State Medicaid Plan that is approved by the Federal Government. That Plan describes the services and benefits the individual is entitled to receive and the conditions of service provision. 133 MEDICAL DIRECTOR – A Board Certified Psychiatrist responsible for establishing and overseeing medical policy throughout the system under the terms of this Contract. MEDICAL NECESSITY - Criteria established to ensure that treatment is essential and appropriate for the condition or disorder for which the treatment is provided. The criteria reference the scope, amount and duration of service appropriate for levels of acuity and rehabilitative care. MEDICARE – A federal government hospital and medical expense insurance plan primarily for elderly people and people with long term disabilities. MEMBER HANDBOOK – A document developed and disseminated by the Contractor according to parameters established in this Contract to inform potential eligible and enrolled persons of their rights, responsibilities and treatment coverage. MEMORANDUM OF AGREEMENT (MOA) or MEMORANDUM OF UNDERSTANDING (MOU) – A written document, signed by two or more parties, containing policies and/or procedures for managing issues that impact more than one agency or program. MH - Mental Health MMIS - Medicaid Management Information System MONITORING – Routine or focused review of documentation of services delivered by provider agencies. MPN – Medicaid Provider Number MST - Multi-Systemic Therapy NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) - A non-profit organization created to improve patient care quality and health plan performance in partnership with system management plans, purchasers, consumers, and the public sector. NATIONAL PRACTITIONER DATA BANK (NPDB) – A database maintained by the federal government that contains information on physicians and other medical practitioners against whom medical malpractice claims have been settled or other disciplinary actions that have been taken. NATURAL AND COMMUNITY SUPPORTS – Composed of places, things, and particularly people who are part of our interdependent community lives and whose relationships are reciprocal in nature. NCQA - National Council for Quality Assurance NEEDS ASSESSMENT - A process by which an individual or system (e.g., an organization or community) examines existing resources to determine what new resources are needed or how to reallocate resources to achieve a desired goal. 134 NORTH CAROLINA SUPPORT NEEDS ASSESSMENT PROFILE (NC-SNAP) – Assessment instrument used to determine the care or supports needed by a person with developmental disabilities. NPI – National Provider Identifier OPERATIONAL AND FINANCIAL REVIEW - Review of the Contractor conducted by DMH/DD/SAS to assess compliance with contract requirements. OUTREACH - Programs and activities to identify and encourage enrollment of individuals in need of MH/DD/SA services and/or to encourage people who have left service prematurely to return. PAC – Provider Advisory Council PATIENT PLACEMENT CRITERIA (PPC) - Standards of, or guidelines for, alcohol, tobacco and other drug (ATOD) abuse treatment that describe specific conditions under which patients should be admitted to a particular level of care (admission criteria), under which they should continue to remain in that level of care (continued stay criteria), and under which they should be discharged or transferred to another level (discharge / transfer criteria). PPC generally describe the settings, staff, and services appropriate to each level of care and establish guidelines based on ATOD diagnosis and other specific areas of patient assessment. PCP - Person Centered Plan PCPM – Per Citizen Per Month. The basis on which the Contractor is paid for administrative functions under the terms of some contracts PEER REVIEW – The analysis of clinical care by a group of that clinician’s professional colleagues. The provider’s care is generally compared to applicable standards of care, and the group’s analysis is used as a learning tool for the members of the group. PENETRATION – The extent to which the system serves those individuals expected to have a specific medical condition, in this case persons with developmental disabilities, persons with mental illnesses and persons with substance abuse disorders. PERFORMANCE INDICATORS - Measurable evidence of the results of activities related to particular areas of concern as indicated in this Contract. The measures are quantitative indicators of the quality of care provided that consumers, payers, regulators and others could use to compare the care or provider to other care or providers. PERFORMANCE STANDARDS- Benchmarks an agency or provider is expected to meet. The standards define regulatory expectations and in meeting them the agency or provider may meet a required level for “certification” or “accreditation”. PERSON-CENTERED PLANNING - A process focused on learning about an individual’s whole life, not just issues related to the person’s disability. The process involves assembling a group of 135 supporters selected by the consumer who are committed to supporting the person in pursuit of desired outcomes. Planning includes discovering strengths and barriers, establishing timelimited and identifying and gaining access to supports from a variety of community resources prior to utilizing the community MHO/DD/SA system to assist the person in pursuit of the life he/she wants. Person-centered planning results in a written plan that is agreed to by the consumer and that defines both the natural and community supports and the services being requested from the public system to achieve the consumer’s desired outcomes. The plan is used as the basis for requesting an authorization for services. PHYSICAL DEPENDENCE - Condition in which the brain cells have adapted as a result of repeated exposure to a drug and consequently require the drug in order to function. If the drug is suddenly made unavailable, the cells become hyperactive. The hyperactive cells produce the signs and symptoms of drug withdrawal. PLAN OF CORRECTION (POC) – A written response to findings of an audit or review that specify corrective action, time frames and persons responsible for achieving the desired outcomes. PREVALENCE – The estimated degree of incidence of a condition in a given population. PREVENTION – Activities aimed at teaching and empowering individuals and systems to meet the challenges of life events and transitions by creating and reinforcing healthy behaviors and lifestyles and by reducing risks contributing mental illness, developmental disabilities and substance abuse. Universal Prevention programs reach the general population; Selective Prevention programs target groups at risk for mental illness, developmental disabilities and substance abuse; Indicated Prevention programs are designed for people who are already experiencing mental illness or addiction disorders. PSR - Psychosocial Rehabilitation RESPONSIBLE CLINICIAN - An assigned professional deemed competent and credentialed by the Contractor to serve as a fixed point of accountability for the consumer’s PCP, monitoring and outreach. PRIMARY CARE - (a) Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians—often referred to as primary care practitioners. (b) Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to secondary care specialists, as necessary. PRIMARY SOURCE VERIFICATION – A process through which an organization validates credentialing information from the organization that originally issued the credential to the practitioner 136 PRINCIPLE DIAGNOSIS - The Principal/Primary Diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Since the Principal/Primary Diagnosis represents the reason for the patient's stay, it may not necessarily be the diagnosis which represents the greatest length of stay, the greatest consumption of hospital resources, or the most life-threatening condition. Since the Principal/Primary Diagnosis reflects clinical findings discovered during the patient's stay, it may differ from Admitting Diagnosis. In the case of admission to the hospital-based ambulatory surgery service or freestanding ambulatory surgery center, the Principal/Primary Diagnosis is that diagnosis established to be chiefly responsible for occasioning the admission to the service or center for the specific procedure. In the case of emergency department visits, the Principal/Primary Diagnosis Code is that diagnosis established to be chiefly responsible for occasioning the visit to the Emergency Department. PRIORITY POPULATIONS – Groups of people within target populations who are considered most in need of the services available within the system. PRIVILEGING – Process for determining, usually through training and supervision that an individual provider has the necessary skills and knowledge to offer designated services and can provide them without supervision. PROMPT SERVICES - Services provided when needed. For target or priority populations, routine appointments within 14 days, initial hospital discharge visits within 3 days, urgent visits within 2 days, emergent visits immediately and no later than 24 hours qualify as prompt. PROVIDER – A person or an agency that provides MH/DD/SA services, treatment, and supports under a subcontract to the LME. OPERATIONS MANUAL – A document attached to a subcontract for the purpose of explaining how to work with the local system, the requirements for service delivery, authorization, claims submission, etc. PROVIDER PROFILING – The process of compiling data on individual provider patterns of practice and comparing those data with expected patterns based on national or local statistical norms. The data may include medication prescribed, hospital length of stay, size of caseload, and other services. Some data may be compiled for use by consumers in choosing preferred providers based on performance indicators. PUBLIC MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES SYSTEM – The network of managing entities, service providers, government agencies, 137 institutions, advocacy organizations, and commissions and boards responsible for the provision of publicly funded services to consumers QA - Quality Assurance QI - Quality Improvement QIC - Quality Improvement Committee QM - Quality Management QP – Qualified Professional QPN - Qualified Provider Network QUALIFIED PROVIDER NETWORK – The group of subcontractors subcontracted by a Contractor to provide supports and services to persons for whom the Contractor authorizes care. QUALITY ASSURANCE (QA) - Involves periodic monitoring of compliance with standards. QUALITY IMPROVEMENT (QI) - Process to assure that services, administrative processes, and staff are constantly improving and learning new and better ways to provide services and conduct business. As distinct from QA, the purpose of QI, also referred to as continuous quality improvement (CQI) is to continuously improve the process and outcome (quality) of treatments, services, and supports provided to consumers and administrative functions. QUALITY OF CARE-as defined by the Institute of Medicine: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” QUALITY OF SERVICE-which may include factors such as hours of operation, ease of access to the premises, service continuum, accreditation and staff credentials. QUALITY MANAGEMENT (QM) - The framework for assessing and improving services and supports, operations, and financial performance. Processes include: QUALITY ASSURANCE, and QUALITY IMPROVEMENT. RECOVERING STAFF - Counselors with and without educational degrees working in the substance abuse treatment fields who are in recovery. RECOVERY – A personal process of overcoming the negative impact of a disability despite its continued presence. Like the victim of a serious accident who undergoes extensive physical therapy to minimize the impact of damaging injuries, people with active addictions as well as serious, disabling mental illnesses and developmental disabilities can also make substantial 138 recovery through symptom management, psychosocial rehabilitation, other services and supports, and encouragement to take increasing responsibility for self. REFERRAL - Establishing a link between a person and another service or support by providing authorized documentation of the person’s needs and recommendations for treatment, services, and supports. It includes follow–up in a timely manner consistent with best practice guidelines. REGISTER – The process of gathering initial data and entering an individual into the service system. REVENUES – Money earned through reimbursements paid for by covered services or other local sources, such as grants, etc. RFP/RFI – Request for Proposal/ Request for Information SA - Substance Abuse SAPT - Substance Abuse Prevention and Treatment STR - SCREENING/TRIAGE – An abbreviated assessment or series of questions intended to determine whether the person needs referral to a provider for services based on eligibility criteria and acuity level. A screening may be done face-to-face or by telephone, by a clinician or paraprofessional who has been specially trained to conduct screenings. Screening is a core or basic service available to anyone who needs it whether or not they meet criteria for target or priority populations. SEAMLESS - Treatment system without gaps or breaks in service, such that persons being served transition smoothly and with ease from one treatment component to another. SELF-DETERMINATION – The right to and process of making decisions about one’s own life. SENTINEL EVENT – CRITICAL INCIDENT, UNUSUAL INCIDENT, ETC. A sentinel event may include any type of incident that is clinically undesirable and avoidable. Sentinel events signal episodes of reduced quality of care. Many organizations monitor medication errors, review of deaths, accidents, evacuation drill responses, rights violations, medical emergencies, use of restraint or seclusion, behavior management etc. The purpose of sentinel event monitoring is to discover root causes and implement a continuous improvement process to prevent further events. SEVERELY EMOTIONALLY DISTURBED (SED) – A designation for people less than 18 years of age who, because of their diagnosis, the length of their disability and their level of functioning, are at the greatest risk for needing services. SEVERELY MENTALLY ILL (SMI) – Refers to adults with a mental illness or disorder that is described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, that impairs or impedes functioning in one or more major areas of living and is unlikely to improve without 139 treatment, services and/or supports. People with serious mental illness are a target or priority population for the public mental health system for adults. SERIOUSLY AND PERSISTENTLY MENTALLY ILL (SPMI) – Refers to people with a mental illness or disorder so severe and chronic that it prevents or erodes development of functional capacities in primary aspects of daily life such as personal hygiene and self care, decisionmaking, interpersonal relationships, social transactions, learning and recreational activities. SPECIALIST REVIEW – A consultation or second opinion rendered by a member of the UM staff when an authorization request falls outside the defined criteria for service selection, amount or duration. STANDARD OF CARE – A diagnostic and/or treatment consensus that a clinician should follow when providing care based upon the discipline’s peer group organization, such as the APA or NASW. STATE – Refers to the State of North Carolina. STATE FUNDED – funded by the state of North Carolina (non-Medicaid) STATE MENTAL HEALTH AUTHORITY – The single State agency designated by each State’s governor to be responsible for the administration of publicly funded mental health programs in the State. In North Carolina that agency is the Department of Health and Human Services. STATE MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCEABUSE SERVICES PLAN – Plan for Mental Health, Developmental Disabilities and Substance Abuse Services in North Carolina. This Statewide plan forms the basis and framework for MH/DD/SA services provided across the State. STATE OR LOCAL CONSUMER ADVOCATE - The individual carrying out the duties of the State Local Consumer Advocacy Program Office STATE PLAN - Annual (each fiscal year) updated comprehensive MH/DD/SAS systems reform plan derived from the systems reform statue and titled “Blueprint for Change”. STATE PLAN (MEDICAID) - The written agreements between the State of NC and CMS which describe how the NC DMH/DD/SAS programs meet all CMS requirements for participation in the Medicaid program and the Children’s Health Insurance Program. STRATEGIC PLAN -an organization's process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy, including its capital and people SUBSTANCE ABUSE(SA) – The DSM IV defines substance abuse as occurring if the person 1) uses drugs in a dangerous, self defeating, self destructive way and 2) has difficulty controlling his use even though it is sporadic, and 3) has impaired social and/or occupational functioning all within a one year period. 140 THE SUBSTANCE ABUSE AND MENTAL HEALTH ADMINISTRATION OF THE FEDERAL GOVERNMENT (SAMHSA) - SAMHSA is an agency of the U.S. Department of Health and Human Service. It is the federal umbrella agency of the Center for Substance Abuse Treatment, Center for Substance Abuse Prevention and the Center for Mental Health Services. SUBSTANCE ABUSE PREVENTION AND TREATMENT BLOCK GRANT (SAPTBG) -A federal program to provide funds to States to enable them to provide substance abuse services SUBSTANCE DEPENDENCE - DSM IV defines substance dependence as requiring the presence of tolerance, withdrawal, and/or continuous, compulsive use over a 1 year period. SUBCONTRACT - Any contract between the Contractor (Contractor) and a third party for the performance of all or a specified part of this Contract. The SUBCONTRACTOR means any third party engaged by the Contractor, in a manner conforming to the SEC contract requirements for the provision of all or a specified part of covered services under this Contract. SYNAR AMENDMENT – Section 1926 of the Public Health Service, is administered through the Substance Abuse Prevention and Treatment (SAPT) Block Grant and requires States to conduct specific activities to reduce youth access to tobacco products. The Secretary of the US Department of Health and Human Services is required by statute to withhold SAPT Block Grant funds (40% penalty) from States that fail to comply with the SYNAR Amendment. SYSTEMIC CHANGE- A change related to the whole organization TARGET POPULATIONS – Groups of people with disabilities with attributes considered most in need of the services available within the system; populations as identified in federal block grant language. NON-TARGET POPULATION are those individuals with less severe disorders that can be adequately and most cost effectively treated by the private sector, primary physicians or by using generic community resources. TRANSITION – The time in which an individual is moving from one life/development stage to another. Examples are the change from childhood to adolescence, adolescence to adulthood and adulthood to older adult. UM - Utilization Management UNIFORM PORTAL ACCESS - The standardized process and procedures used to ensure consumer access to, and exit from, public services in accordance with the State Plan. UTILIZATION MANAGEMENT (UM) - Process to regulate the provision of services in relation to the capacity of the system and needs of consumers. This process should guard against underutilization as well as over-utilization of services to assure that the frequency and type of services fit the needs of consumers. The administration of services or supplies which meet the following tests: they are appropriate and necessary for the symptoms, diagnosis, or treatment 141 of the medical condition; they are provided for the diagnosis or direct care and treatment of the medical condition; they meet the standards of good medical practice within the medical community in the service area; they are not primarily for the convenience of the plan member or a plan provider; and they are the most appropriate level or supply of service which can safely be provided. This function is carried out by professionals qualified in disciplines related to the care being authorized and requires their use of tools such as service definitions, level of care criteria, etc. UTILIZATION - The use of services. Utilization is commonly examined in terms of patterns or rates of use of a single service or type of service. Use is expressed in rates per unit of population at risk for a given period such as the number of admissions to the hospital per 1,000 persons per year, or the number of services provided per 1,000 persons by a system of care annually. UTILIZATION REVIEW (UR) –An analysis of services, through systematic case review, with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided. The examination of documents and records to assure that services that were authorized were in fact provided in the right amount, duration and scope, within the time frames allotted; and that consumers benefit from the service. The review also examines whether the actual request for authorization was valid in its assessment of the consumer and the intensity of need. There are a variety of types of reviews that may occur concurrent with the care being provided, retrospectively or in some cases prospectively if there are questions about the authorization. VERIFICATION OF EXPERIENCE –primary source confirmation of information that has been provided by a potential employee to serve as work experience that would contribute to qualifications for Qualified Mental Health/Substance Abuse/Developmental Disability Professional status or to meet service definition requirements 142 Appendices 143 Official Communication Memos CoastalCare Communication Memos can be found on the CoastalCare website on the provider page. 144 Code of Ethics Policy COASTALCARE Section: Administration Policy No. 105 Subject: Code of Ethics Effective Date: July 12, 2012 Reference: URAC Core 4, 27 PURPOSE: The purpose of this policy is to establish the agency expectations regarding staff behavior in carrying out their official duties on behalf of the public for whom the agency serves. POLICY: It is the policy of this agency that employees act with ethical responsibility in the execution of their duties; that decisions are made within the proper channels of the agency structure according to the guidance of agency policies; that employment is not used for personal gain so that the public may have confidence in the integrity of this public agency. Therefore it is required that: Employees shall act in accordance with the ethics of his/her profession as established by the relevant licensing board. Employees shall demonstrate compassion, honesty, integrity and respect in their dealings with consumers, providers and the public. Employees shall protect consumer confidentiality within the constraints of the law. Employees shall not utilize their position with the agency for personal gain. Any violation of this policy shall be deemed unacceptable personal conduct and will result in disciplinary action up to or including termination of employment. Revision History: 145 Revision 0 Date Description of changes 05/28/2009 Initial Release 11/18/2010 Annual Area Board Review 10/27/2011 Annual AB Review 07/12/2012 Adopted by CoastalCare Area Board 146 Federal State and Local Requirements Below is a comprehensive list of federal, state and local requirements for CoastalCare and providers. It serves as sufficient and necessary direction to providers for accessing pertinent rules, regulations and standards. These documents change based on legislative action, change in federal and state policy, and procedures. There is a mutual responsibility for CoastalCare and providers to each routinely check these items for updates on requirements. If a Provider has problems obtaining or understanding the information referenced in this section, please contact your liaison. Federal Rules and Regulations Rule / Regulation Source Access 42 Code of Federal Regulations(CFR) 434.6 and 438.6 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=7f8797ace4aef69f7dcc39e dc5bfbc06&tpl=/ecfrbrowse/Title42/42cfr4 38_main_02.tpl http://www.gpo.gov/fdsys/pkg/CFR-2011title42-vol4/pdf/CFR-2011-title42-vol4sec438-10.pdf Managed Care Organization Contract Requirements 42 Code of Federal Regulations(CFR) 438 Subpart F http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=7f8797ace4aef69f7dcc39e dc5bfbc06&rgn=div6&view=text&node=4 2:4.0.1.1.8.6&idno=42 Grievances and Appeals 42 Code of Federal Regulations(CFR) 438.114(d) http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=7f8797ace4aef69f7dcc39e dc5bfbc06&rgn=div8&view=text&node=4 2:4.0.1.1.8.3.106.6&idno=42 Emergency and Post-Stabilization Care Services 42 Code of Federal Regulations(CFR) 438.206 438.208 and 438.210 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl Access Standards 42 Code of Federal Regulations(CFR) 438.208 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=7f8797ace4aef69f7dcc39e dc5bfbc06&rgn=div8&view=text&node=4 2:4.0.1.1.8.4.106.6&idno=42 Coordination and Continuity of Care 42 Code of Federal http://ecfr.gpoaccess.gov/cgi/t/text/text- Structure and Operations Standards 42 Code of Federal Regulations(CFR) 438 42 Code of Federal Regulations(CFR) 438.10(c)(5) Brief Description Managed Care Interpreter Services - special needs 147 Regulations(CFR) 438.214, 438.218, 438.224, 438.226, and 438.230 Rule / Regulation idx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl Source Access Brief Description 42 Code of Federal Regulations(CFR) 438.236, 438.240 and 438.242 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl Measurements and Improvement Standards 42 Code of Federal Regulations(CFR) 438.240 Quality Assessment and Performance Improvement Program Standards 42 Code of Federal Regulations(CFR) 438.610(a) and (b) http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=04802f56faafe4c208ec4ca9a8a4ef 76&c=ecfr&tpl=/ecfrbrowse/Title42/42tab _02.tpl http://www.gpo.gov/fdsys/pkg/CFR-2011title42-vol4/pdf/CFR-2011-title42-vol4sec438-610.pdf 42 Code of Federal Regulations(CFR) 447.45 and Section 1902(a) (37)(A) of the Social Security Act http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr;sid=6c7c5c6b3672320dd28022 43e5e5793f;rgn=div5;view=text;node=42 %3A4.0.1.1.12;idno=42;cc=ecfr Timely Claims Payment Standard 42 Code of Federal Regulations(CFR) 438.310 through 438.370 42 Code of Federal Regulations(CFR) 455 Subpart A 42 Code of Federal Regulations(CFR) 456 and 438 Subpart D 42 Code of Federal Regulations (CFR) 438.10 42 Code of Federal Regulations(CFR) 483.430(a) 42 Code of Federal Regulations (CFR) Part 2 Confidentiality of Alcohol and Drug Abuse Patient http://www.ssa.gov/OP_Home/ssact/title19 /1902.htm http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&rgn=div6&view=text&node=4 2:4.0.1.1.13.1&idno=42 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr;sid=6c7c5c6b3672320dd28022 43e5e5793f;rgn=div5;view=text;node=42 %3A4.0.1.1.14;idno=42;cc=ecfr http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr;sid=6c7c5c6b3672320dd28022 43e5e5793f;rgn=div5;view=text;node=42 %3A4.0.1.1.8;idno=42;cc=ecfr#42:4.0.1.1. 8.1.106.5 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=0d2c79637fea4d732992f2 a39cee7b04&rgn=div5&view=text&node= 42:5.0.1.1.2&idno=42#42:5.0.1.1.2.9.7.5 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=4da168159410f50d6815d 4a79a0da210&rgn=div5&view=text&node =42:1.0.1.1.2&idno=42 External Quality Review Standards Prohibited affiliations with individuals debarred by Federal agencies Medicaid Agency Fraud Detection and Investigation Program Utilization Control Information Requirement Standards - New Enrollee Information Participation: Facility Staffing (Intermediate Care Facility for the Mental Retarded (ICF-MR) for Qualified MR Professional Federal regulations upon the disclosure and use of drug abuse patient records 148 Records 5 United States Code (U.S.C.)§ 1-13 (Public Law 95-452) http://www.law.cornell.edu/uscode/html/us code05a/usc_sup_05_5_10_sq2.html Outlines mission of the Office of Inspector General Inspector General Act of 1978 Rule / Regulation Source Access 5 United States Code (U.S.C.) http://www.osc.gov/haStateLocalStatute.ht § 1501 – 1508 m Brief Description Restricts the political activity of individuals principally employed by state or local executive agencies Federal Political Activities Act (Hatch Act) 31 United States Code (U.S.C.). 3729-3733 http://www.taf.org/federalfca.htm Federal False Claims Act http://www.law.cornell.edu/uscode/text/31/ subtitle-III/chapter-38 Administrative remedy against any person who makes, or causes to be made, a false claim or written statement to any of certain Federal agencies 41 United States Code (U.S.C.) http://www.gpo.gov/fdsys/pkg/USCODE2010-title41/pdf/USCODE-2010title41.pdf Public contracts 42 United States Code (U.S.C.)68 http://www.law.cornell.edu/uscode/pdf/lii_ usc_TI_42_CH_68.pdf Outlines measures, designed to assist the efforts of affected States in expediting the rendering of aid, assistance, and emergency services, and the reconstruction and rehabilitation of devastated areas Act to improve patient safety and reduce incidence of events that adversely effect patient safety Federal False Claims Act 31 United States Code (U.S.C.)3801-3812 Program Fraud Civil Remedies Act of 1986 Disaster Relief 42 United States Code (U.S.C.)299b–21, Section 922-926 The Patient Safety and Quality Improvement Act of 2005 42 United States Code (U.S.C.)1320a-7 and Section 1128 of the Social Security Act 42 United States Code (U.S.C.)1320a-7a http://www.pso.ahrq.gov/statute/pl10941.pdf http://www.law.cornell.edu/uscode/text/42/ 1320a-7 http://www.socialsecurity.gov/OP_Home/s sact/title11/1128.htm http://www.law.cornell.edu/uscode/text/42/ 1320a-7a Exclusion of certain individuals and entities from participation in Medicare and State health care programs Civil Monetary Penalties 149 Civil Monetary Penalties Law (CMPL) 42 United States Code (U.S.C.)1320a-7b(b) http://www.law.cornell.edu/uscode/text/42/ 1320a-7b Illegal remunerations Anti-Kickback Statue 42 United States Code (U.S.C.)§ 2000d –2000d-7 http://www.justice.gov/crt/about/cor/coord/ titlevistat.php Prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance. Title VI of the Civil Rights Act of 1964 Rule / Regulation Source Access Brief Description 42 United States Code (U.S.C.). § 2000e – 2000e17 http://www.justice.gov/crt/about/emp/docu ments/Title_VII_Statute.pdf Prohibits employment discrimination based on race, color, religion, sex and national origin Title VII of the Civil Rights Act of 1964 45 Code of Federal Regulations (CFR) Subchapter C Parts 160, 162& 164 http://ecfr.gpoaccess.gov/cgi/t/text/textidx?sid=057089847e76aa7928738f0754a9 2896&c=ecfr&tpl=/ecfrbrowse/Title45/45c frv1_02.tpl Federal Guidelines for Administrative Data Standards and Related Requirements Standards for Privacy of Health Information American Recovery and Reinvestment Act of 2009 http://www.hhs.gov/recovery/overview/ind ex.html Created to “jumpstart” economy, create/save jobs, and put down payment on addressing longneglected challenges Equal Opportunity for Individuals with Disabilities Index to all sections and titles of the Act Medicaid Integrity Program Americans with Disabilities Act (ADA) of 1990 Balanced Budget Act of 1997 Section 1936 of the Social Security Act http://www.ada.gov/pubs/adastatute08.pdf http://thomas.loc.gov/cgibin/query/z?c105:H.R.2015.ENR: http://www.ssa.gov/OP_Home/ssact/title19 /1936.htm http://www.cms.gov/DeficitReductionAct/ Downloads/CMIP2009-2013.pdf Comprehensive Medicaid Integrity Plan for FY2009-2013 fraud, waste, and abuse of the Medicaid program. http://www.ncdhhs.gov/dma/program%20i ntegrity/Special%20Bulletin102011.pdf Special Bulletin-Program Integrity Unit 41 United States Code (U.S.C.). Chapter 10, Section 701 http://www.gpo.gov/fdsys/pkg/USCODE2009-title41/pdf/USCODE-2009-title41chap10-sec701.pdf Drug-free Workplace Requirements Drug-Free Workplace Act of 1998 Emergency Support Function #8 http://www.fema.gov/pdf/emergency/nrf/nr f-esf-08.pdf Outlines mechanisms for coordinated Federal assistance to supplement State, tribal, and local Centers for Medicare & Medicaid Services (CMS) Medicaid Integrity Program 150 resources in response to a public health and medical disaster Promoting Quality and Efficient Healthcare in Federal Government Administered or Sponsored Health Care Programs. CMS Quality Framework Executive Order 13410 http://archive.hhs.gov/valuedriven/index.ht ml Fair Labor Standards Act (FLSA) http://www.dol.gov/whd/regs/statutes/Fair LaborStandAct.pdf Family and Medical Leave Act (FMLA) http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=d178a2522c85f1f401ed3f 3740984fed&rgn=div5&view=text&node= 29:3.1.1.3.54&idno=29 The establishment of fair labor standards in employments (05/2011) Outlines to take job-protected, unpaid leave, or substitute appropriate paid leave for “eligible” employees of a covered employer Source Access Brief Description Health Information Technology for Economic and Clinical Health (HITECH) Act http://www.hhs.gov/ocr/privacy/hipaa/adm inistrative/enforcementrule/hitechenforcem entifr.html Health Information Technology for Economic and Clinical Health (HITECH) Act Health Insurance Portability and Accountability Act (HIPAA) of 1996 http://www.hhs.gov/ocr/privacy/hipaa/adm inistrative/statute/index.html Homeland Security Presidential Directive/HSPD5 Occupational Safety and Health (OSH) Act of 1970 http://www.fas.org/irp/offdocs/nspd/hspd5.html Standards and requirements for transmitting certain health information to improve the efficiency and effectiveness of the health care system while protecting patient privacy Management of Domestic Incidents Rule / Regulation Office of Management and Budget – Circular A-133 Office of Management and Budget – Circular A-87 http://www.osha.gov/pls/oshaweb/owasrch .search_form?p_doc_type=OSHACT&p_t oc_level=0&p_keyvalue=&p_status=CUR RENT http://www.whitehouse.gov/sites/default/fil es/omb/assets/OMB/circulars/a133_compli ance/2011/Compliance_Supplement_Marc h-2011.pdf http://www.whitehouse.gov/omb/circulars_ a087_2004 Office of Workers’ Compensation Programs http://www.dol.gov/owcp/ Patient Protection and http://www.healthcare.gov/law/full/ Safe and healthful working conditions for working men and women Provides for the issuance of a Compliance Supplement to assist auditors in performing the required audits Standards for determining costs for Federal awards carried out through grants, cost reimbursement contracts, and other agreements with State and local governments Outlines the four major disability compensation programs which provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents Quality, affordable healthcare for 151 Affordable Care Act (PPACA) all Americans Public Law 103-227 Part C http://www2.ed.gov/policy/elsec/leg/esea0 2/pg56.html Smoking prohibition Public Law 106-390 http://www.disastersrus.org/fema/stafact.ht m Federal Emergency Management Findings, Declarations and Definitions Robert T. Stafford Disaster Relief and Emergency Assistance Act http://www.au.af.mil/au/awc/awcgate/crs/rl 33090.pdf Public Law 109-171 http://www.gpo.gov/fdsys/pkg/PLAW109publ171/pdf/PLAW-109publ171.pdf Federaland State Roles in Declarations of an Emergency(2005) Key Medicaid Program Revisions Deficit Reduction Act (DRA) of 2005 Rule / Regulation Public Law 111-5, Section 5006 of the American Recovery and Reinvestment Act (ARRA) Public Law 111–152 Source Access Brief Description http://www.gpo.gov/fdsys/pkg/PLAW111publ5/pdf/PLAW-111publ5.pdf Services by Indian Health Care Providers http://www.gpo.gov/fdsys/pkg/PLAW111publ152/pdf/PLAW-111publ152.pdf Section 1867 of the Social Security Act http://www.ssa.gov/OP_Home/ssact/ssacttoc.htm http://www.ssa.gov/OP_Home/ssact/title18 /1867.htm Section 1877 of the Social Security Act http://www.socialsecurity.gov/OP_Home/s sact/title18/1877.htm Guidelines to help lower the funding requirement for compliance program to anyone who receives any federal funding Allows private individuals to file lawsuits under the Federal False Claims Acts on behalf of the federal and state governments to recover funds stolen through fraud. Table of Contents for the Social Security Act Examination and Treatment for Emergency Medical Conditions and Women in Labor Limitation on certain physician referrals Stark Law Title 19 of the Social Security Act http://www.ssa.gov/OP_Home/ssact/title19 /1900.htm Grants to States for Medical Assistance (Sections 1900 -1946) http://www.ssa.gov/OP_Home/ssact/title19 /1903.htm Disclosure of business transaction information - parties of interest Health Care and Education Reconciliation Act of 2010 Qui Tam or Whistleblower Provisions Social Security Act Sections 1903(m) (2) (A) (viii) and 1903(m) (4) of the Social Security Act http://baronandbudd.com/areas-ofpractice/qui-tam-false-claims-act/qui-tamwhistleblower-provisions/ Public Health Service Act 152 Section 1905(r)(5) of the Social Security Act http://www.ssa.gov/OP_Home/ssact/title19 /1905.htm EPSDT Services The Rehabilitation Act of 1973, Section 503 http://www.dol.gov/compliance/laws/comp -rehab.htm U.S. Sentencing Guidelines http://www.ussc.gov/Guidelines/index.cfm Act prohibits discrimination and requires employers to take affirmative action to hire, retain, and promote qualified individuals with disabilities. Sentencing guidelines, legal offenses, penalties State Rules/Regulations Rule / Regulation Source Access 10A North Carolina Administrative Code (NCAC) 26B http://reports.oah.state.nc.us/ncac/title%20 10a%20%20health%20and%20human%20services /chapter%2026%20%20mental%20health,%20general/subchap ter%20b/subchapter%20b%20rules.html Rule / Regulation Source Access Brief Description NC Mental Health Confidentiality Rules Brief Description Division of Medical Assistance (DMA) Clinical Coverage Policy 8-A http://www.ncdhhs.gov/dma/mp/8A.pdf Enhanced Mental Health and Substance Abuse Services (08/2011) Division of Medical Assistance (DMA) Clinical Coverage Policy 8B Division of Medical Assistance (DMA) Clinical Coverage Policy 8C http://www.ncdhhs.gov/dma/mp/8B.pdf Inpatient Behavioral Health Services Provided http://www.ncdhhs.gov/dma/mp/8C.pdf Outpatient Behavioral Health Services Provided by Direct Enrolled Providers Division of Medical Assistance (DMA) Clinical Coverage Policy 8D-1 http://www.ncdhhs.gov/dma/mp/8D1.pdf Psychiatric Residential Treatment Facilities for Children under the Age of 21 Division of Medical Assistance (DMA) Clinical Coverage Policy 8D-2 Division of Medical Assistance (DMA) Clinical Coverage Policy 8E http://www.ncdhhs.gov/dma/mp/8D2.pdf Residential Treatment Services http://www.ncdhhs.gov/dma/mp/8E.pdf Intermediate Care Facilities for Individuals with Mental Retardation Division of Medical Assistance (DMA) Clinical Coverage Policy 8L http://www.ncdhhs.gov/dma/mp/8L.pdf Targeted Case Management for Mental Health and Substance Abuse 153 Division of Medical Assistance (DMA) Clinical Coverage Policy 8M http://www.ncdhhs.gov/dma/mp/8M.pdf Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP- MR/DD) Division of Medical Assistance (DMA) Clinical Coverage Policy 8N http://www.ncdhhs.gov/dma/mp/8n.pdf Intellectual and Developmental Disabilities Targeted Case Management Division of Medical Assistance (DMA) Clinical Coverage Policy – 8O http://www.ncdhhs.gov/dma/mp/A4.pdf Services for Individuals with Intellectual and Developmental Disabilities with Mental Health or Substance Abuse Co-Occurring Disorders Division of Medical Assistance (DMA) Medicaid Bulletins http://www.ncdhhs.gov/dma/bulletin/index .htm N.C. Medicaid general and special bulletins NC Division of MH/DD/SAS Policies http://www.ncdhhs.gov/mhddsas/statspubli cations/Policy/index.htm NC Division of MH/DD/SAS Policies NC Statewide Technical Architecture – Security Domain http://www.ncsta.gov/library/pdf/Security. pdf Guidelines to implement proven security policies, procedures and controls Rule / Regulation Source Access Brief Description NCDivision of MH/DD/SAS North Carolina Department of Health and Human Services (DHHS) and LME Performance Contract Attachment I – Scope of Work Attachment II – Performance Expectations Attachment III – Financing Attachment IV – Data Use Agreement Attachment V – Informatics Center System Access Agreement http://www.ncdhhs.gov/mhddsas/statspubli cations/Contracts/DHHSLMESFY11Contract.pdf Performance Contracts and outline of contract reporting requirements NCDivision of MH/DD/SAS – Block Grant Audit Tools for Substance Abuse and Community Mental Health http://www.ncdhhs.gov/mhddsas/providers /Audits/index.htm Index of State audits and monitoring assessments 154 NCDivision of MH/DD/SAS – Community Alternatives Program for Persons with MR/DD (CAP MR/DD) Manuals http://www.ncdhhs.gov/mhddsas/provide rs/CAPMRDD/cap-waiverforumfacts9-2408.pdf http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/cap-compmanual7-21.pdf http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/cap-supportsmanual721.pdf NCDivision of MH/DD/SAS – Community Systems Progress Reports NCDivision of MH/DD/SAS – Developmental Disabilities Service Definitions NCDivision of MH/DD/SAS – Disaster preparedness Response and Recovery Plan for the State NCDivision of MH/DD/SAS – Guide to Standardized Administration of the Frequency & Extent Monitoring Tool and the Provider Monitoring Tool Overview of New CAP-MR/DD Waivers 2008 CAP-MR/DD Comprehensive Waiver (Released 7/21/10) 2008 CAP-MR/DD Supports Waiver (Released 7/21/10) http://www.ncdhhs.gov/mhddsas/statspubli cations/Reports/DivisionInitiativeReports/c ommunitysystems/index.htm http://www.ncdhhs.gov/mhddsas/providers /developmentaldisabilities/index.htm Quarterly progress report on performance indicators as outlined in the contract Index of information regarding Developmental Disabilities http://www.ncdhhs.gov/mhddsas/services/ disasterpreparedness/ Information for State Disaster Preparedness http://www.ncdhhs.gov/mhddsas/providers /providerendorsement/revisedfempmtmanual11-12-10.pdf Senate Bill 163 monitoring process and specific instructions on the use of each tool Rule / Regulation Source Access Brief Description NCDivision of MH/DD/SAS – Implementation Updates http://www.ncdhhs.gov/mhddsas/impleme ntationupdates/index.htm Index of Enhanced benefit services updates NC Division of MH/DD/SAS – LME and Provider Contract http://www.ncdhhs.gov/mhddsas/statspubli cations/Contracts/contractlmeprovider.pdf Outlines provider contract requirements NC Department of Health and Human Services/Division of Medical Assistance and Managed Care Organization (MCO) Contract NCDivision of MH/DD/SAS – Performance Contract Report/Data Submission Requirement Reports NCDivision of MH/DD/SAS – Provider Monitoring http://www.ncdhhs.gov/dma/lme/MCOFIN ALContract10042011.pdf Outlines MCO contract requirements http://www.ncdhhs.gov/mhddsas/statspubli cations/Reports/DivisionInitiativeReports/ pc-reports/index.html Quarterly schedule of report submission requirements as outlined in contract http://www.ncdhhs.gov/mhddsas/providers /providermonitoring/index.htm Index of review tools for the North Carolina Gold Star Rating and Monitoring Process for Providers (07/2012) 155 North Carolina Administrative Rules – APSM 10-6 http://www.records.ncdcr.gov/local/2011 _10_LMESchedule_Official.pdf North Carolina Administrative Rules – APSM 30-1 http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/apsm30-1_11-11.pdf Records Retention and Disposition Schedule NCDivision of MH/DD/SAS Local Management Entity (10/2011) Rules for MHDDSA Facilities & Services (11/2011) North Carolina Administrative Rules – APSM 45-1 North Carolina Administrative Rules – APSM 45-2 North Carolina Administrative Rules – APSM 75-1 North Carolina Administrative Rules – APSM 95-2 North Carolina Division of Health Service Regulation http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/apsm451confidentialityrules1-1-05total.pdf http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/rmdmanual-final.pdf Confidentiality Rules for MH/DD/SA Services Manual (01/2005) Record Management and Documentation Manual (03/2009) http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/Archive/apsm751budget7-95.pdf http://www.ncdhhs.gov/mhddsas/statspubli cations/Manuals/apsm95-2clrights7-03.pdf Area Program Budgeting and Procedures Manual (07/1995) North Carolina False Claims Act (House Bill 1135) http://www.ncleg.net/Sessions/2009/Bills/ House/PDF/H1135v8.pdf North Carolina General Statutes 75-65 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=75-65 North Carolina General Statute 108A-70.10 http://www.ncleg.net/gascripts/Statutes/Sta tutesTOC.pl?Chapter=0108A Rule / Regulation http://www.ncdhhs.gov/dhsr/ Source Access Client Rights Rules in Community MH/DD/SA Services Manual (07/2003) Oversees medical, mental health and adult care facilities, emergency medical services, and local jails Act that deters and punishes persons who make false or fraudulent claims for payment by the state. Protection from Security Breaches NC Medicaid Fraud Brief Description North Carolina General Statute 108C http://www.ncga.state.nc.us/Sessions/2011/ Bills/Senate/PDF/S496v5.pdf Medicaid and Health Choice Provider Requirements North Carolina General Statutes 121, Section 5 & 132 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=121-5 Public Records & Archives http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=132 North Carolina General Statutes 122C http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=122C North Carolina General Statutes 126 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=126 North Carolina General Statutes 132-1.10 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=132-1.10 Public Records Mental Health, Developmental Disability, and Substance Abuse Act of 1985 State Personnel System Social Security Numbers and Other Personal Identifying Information 156 North Carolina General Statute 147-64.7 http://www.ncga.state.nc.us/enactedlegislat ion/statutes/pdf/byarticle/chapter_147/artic le_5a.pdf State auditor access to persons and records North Carolina General Statutes 159; Article 3 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=159 Local Government Budget and Fiscal Control Act North Carolina General Statutes 166a-6 http://www.ncleg.net/gascripts/statutes/stat utelookup.pl?statute=166a-6 North Carolina State of Disaster North Carolina Health Care Personnel Registry https://www.ncnar.org/index1.jsp Registry of unlicensed health care workers, reportable allegations registry 157
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