Revision 13-3; Effective August 1, 2013

 

 

10100 Medically Dependent Children Program Utilization Review

Revision 12-3; Effective November 1, 2012

 

On March 1, 2009, the Department of Aging and Disability Services (DADS) implemented processes for utilization review (UR) in the Medically Dependent Children Program (MDCP). The UR process includes concurrent reviews of a random sample of existing MDCP cases.

 

10110 New Service Limit Exception Procedures and Utilization Review

Revision 12-3; Effective November 1, 2012

 

The utilization review (UR) process ensures the appropriateness of services in service plans.

If concurrent UR findings result in an increase in services over the new service limit, the case manager checks Yes in the New Service Limit Exceeded Due to UR box on Form 2444, New Service Limit Exception Criterion, and processes the individual plan of care (IPC) following current procedures.

If the concurrent UR finding reduces a service that was previously authorized, including authorized services that were granted an exception, the case manager follows current procedures for the IPC change. The case manager must not complete Form 2444 if the UR finding reduces the amount of an authorized service to an amount below the new service limit.

 

10200 Concurrent Reviews

Revision 12-3; Effective November 1, 2012

 

The utilization review (UR) nurse completes concurrent reviews on a random sample of individuals receiving services. The UR nurse will contact the case manager and request all or a portion of the case file documentation that supports authorization of Medically Dependent Children Program (MDCP) services. The case manager will provide the documentation within seven calendar days of the request. Depending on available information, the UR nurse will complete a desk review and may conduct a visit to the individual’s home, the Home and Community Support Services Agency (HCSSA), or both.

The UR documentation, the referral packet and UR nurse observations will be reviewed by the UR nurse manager, if a concurrent UR finding:

  • results in a decrease, increase or denial of services;
  • identifies a policy compliance issue; or
  • identifies a quality of care issue.

Concurrent UR with Findings

If the UR nurse manager concurs with the UR nurse observations, he will indicate recommended changes on the UR tool Summary page and email the UR tool to the regional director or his designee of the region where the individual resides.

The regional director or designee will review the case file and will contact the UR nurse manager, state office UR manager, or both, for any additional UR finding information needed. UR staff will immediately provide additional requested information to the regional director. If the regional director agrees with the UR finding, within one working day he will direct the case manager to implement the UR finding.

Concurrent UR with No Findings

The UR nurse will contact the case manager via telephone or email to inform the case manager there were no findings.

 

10210 When a Fair Hearing is Pending

Revision 13-3; Effective August 1, 2013

When a case file is selected for concurrent review and a fair hearing is pending, the case manager must inform the utilization review (UR) nurse that a fair hearing is pending. The case manager does not submit the case file for concurrent review. UR will then replace the case with another randomly selected case record for concurrent review.

 

10220 When a Fair Hearing Has Been Rendered

Revision 13-3; Effective August 1, 2013

When a case file is selected for concurrent review and a fair hearing decision has been rendered during the current individual plan of care (IPC) year, the case manager must inform the utilization review (UR) nurse of the fair hearing decision details by providing the UR nurse with a copy of the final order submitted by the hearings officer. The case manager must provide specific information to the UR nurse about the service(s) appealed and the actions the case manager took to implement the hearings officer’s decision. The case manager submits the case record for concurrent review.

 

10300 Utilization Review Observations and Findings

Revision 12-3; Effective November 1, 2012

 

 

10310 Reporting Observations by the Utilization Review Nurse

Revision 12-3; Effective November 1, 2012

 

When the Utilization Review (UR) nurse is ready to present initial observations to the case manager, the UR nurse contacts the case manager by phone. If the case manager is not immediately available at the first contact, a request for the case manager to contact the UR nurse is left in a phone mail message and is sent via email with a copy to the supervisor and program manager. The case manager notifies the supervisor and program manager when contact with the UR nurse has been made. If the case manager is available to hear UR observations by phone or in person, the case manager notifies the supervisor and program manager via email of receipt and content of the UR observations. If the case manager is not available, a regional staff member (i.e., supervisor or program manager) should contact the UR nurse by close of business the same day, but no later than close of business the second day following the date of the attempted UR contact.

At the time of regional contact, the UR nurse will share observations. The region is offered an opportunity to provide additional information, documentation, or both, preferably by close of business the same day, but no later than close of business the second business day following the date of contact with the UR nurse. If the UR nurse recommends changes to the individual’s individual plan of care (IPC) that is not supported by policy, the case manager must inform the UR staff of the reason prohibiting implementation of the recommendation. For example, if the UR nurse recommends a minor home modification (MHM) when the individual has already exhausted the MHM service limit, the case manager must inform the UR nurse the individual has reached the service limit and no additional MHM funds are available to implement the recommendation.

Within four working days of receiving feedback from the case manager and Home and Community Support Services Agency (HCSSA), the UR nurse will complete the review and forward the preliminary tool with observations to the UR nurse manager.

An observation by the UR nurse is not considered a finding to be referred until:

  • the region, HCSSA, or both, are afforded the opportunity to provide additional information; and
  • the UR nurse manager concurs with the observation.

 

10320 Utilization Review Finding Reports to the Regional Director

Revision 12-3; Effective November 1, 2012

 

Within seven working days of receiving the file from the utilization review (UR) nurse, the UR nurse manager will:

  • discuss the review of the case record with the UR nurse;
  • make any needed changes or corrections to the initial observation; and
  • report the UR finding to the regional director.

 

10330 Regional Director Response to Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

The regional director has five working days following receipt of information from the utilization review (UR) nurse manager to respond to the UR finding. During this time, the regional director may:

  • agree with the UR finding and direct the case manager to implement the finding, if indicated;
  • discuss the finding with the UR nurse manager through an informal exception process; or
  • file with state office a formal exception to the UR finding.

If no formal exception is filed and the UR finding recommends a change to the existing service plan, the five-working-day time frame is part of the 14-calendar-day time frame a case manager has to complete a change request.

If the regional director attempts to contact the UR nurse manager by phone to discuss the findings in an informal exception process, and the UR nurse manager is not available, the UR nurse manager or designee will return the contact within two business days. If discussion (informal exception process) between the UR nurse manager and the regional director results in changes to the UR finding, the UR nurse manager makes the changes on the electronic version of the UR tool and emails the final copy of the revised tool to the regional director or his designee. If the UR finding is not changed through the informal exception process and the regional director disagrees with the final findings, the region can either:

  • note the disagreement and direct regional staff to implement the finding, if indicated; or
  • file a formal exception with state office. If a formal exception is filed, the regional director will notify the UR nurse manager via phone or email of the date the exception is filed.

 

10340 Final Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

A utilization review (UR) finding will be considered final when:

  • UR unit staff have not been notified of an informal or formal exception within five working days of the referral from the UR nurse manager to the regional director;
  • regional staff agree with the UR finding or do not agree with the UR finding but decide not to use the exception process; or
  • state office staff issued an exception decision.

Note: Agreement or disagreement with the UR finding is focused on decisions made about the individual’s condition or circumstances at the time of the UR, not to service authorization decisions necessitated by changes to the individual’s condition or circumstances that occur after the UR.

 

10350 Exception Process for Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

If the regional director disagrees with utilization review (UR) finding, he will refer the UR finding via email and telephone within five working days to the designated state office Community Services and Program Operations (CSPO) staff. All requests for formal exceptions must include appropriate supporting documentation.

The state office CSPO staff will then make a final decision on whether to implement, revise or reverse the UR finding. State office CSPO staff will issue a decision within seven working days of receipt of the exception and notify the regional director and designated state office staff within one working day of the decision.

 

10400 Implementation of Utilization Review Observations, Recommendations and Findings

Revision 12-3; Effective November 1, 2012

 

When a case manager or alternate regional staff is notified by the utilization review (UR) nurse of an informal observation, before a UR finding is finalized related to case manager compliance with policy (for example, no documentation of medical necessity, delinquent assessment, etc.) and the regional staff agree with the UR observation, the regional staff may make corrections at the time of initial notification by the UR nurse and inform the UR nurse what actions have been taken.

The 14-calendar-day time frame for the case manager to complete a change request begins on the date:

  • the UR nurse manager notifies the regional director of the UR findings, unless a formal exception is made; or
  • state office staff issue a decision on a formal exception.

If necessary, the case manager notifies the Home and Community Support Services Agency (HCSSA) of needed changes and coordinates with the HCSSA to make changes.

Once the UR is complete, UR staff send the review tool documenting the finding to the regional director. The regional director or designee notifies the case manager to implement the UR finding and provides the date for completion and any specific instructions regarding the UR finding.

Under no circumstances should the entire UR tool be filed in the case record. The case manager follows the following for UR documentation in the case record:

UR Finding Case Record Contents
Concurrent review with no findings The UR tool will not be forwarded to the case manager and no documentation is required in the case record.
Concurrent review with findings A copy of the Summary page(s) and all service planning documents completed by the UR nurse must be filed in the case record.

 

10410 Implementation of Utilization Review Findings

Revision 12-3; Effective November 1, 2012

 

Once the regional director or designee notifies the case manager to implement the utilization review (UR) finding, and within 14 days of the date the UR nurse notifies the regional director or designee of the UR finding, the case manager must complete the case action. The case action may include adding, increasing, decreasing, terminating MDCP services or documenting the individual did not agree with the addition/increase of services. For the addition/increase of adaptive aids or minor home modifications, the case manager must contact the primary caregiver within the 14-day time frame to initiate the procurement process for these services. The primary caregiver remains responsible for obtaining written specifications and bids.

 

10420 Case Manager Procedures for Completing Changes

Revision 12-3; Effective November 1, 2012

 

The case manager follows policy in Section 5100, Changes to the Individual Plan of Care (IPC), to complete changes resulting from a utilization review (UR) finding. The case manager must complete the change within 14 calendar days of the date the UR nurse manager notifies the regional director. The case manager:

  • discusses the UR finding and IPC change with the individual/primary caregiver;
  • documents on the IPC or Form 2405, Narrative Notes, in the case file the individual/primary caregiver "verbally agrees" if he agrees with the change or "does not agree" if he disagrees;
  • completes Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and all applicable service authorization forms documenting the action taken;
  • registers the change in the Service Authorization System (SAS), if applicable; and
  • sends a copy of Form 2065-B or Form 2065-C, all applicable service authorization forms and applicable IPC forms to the individual/primary caregiver and provider(s).

The case manager must ensure all service criteria for items/services are met when completing changes.

 

10430 Individual’s Agreement/Disagreement with the IPC Change

Revision 12-3; Effective November 1, 2012

 

The individual/primary caregiver may agree or disagree with the utilization review (UR) finding when the case manager reviews the change request with the individual. The case manager completes the change action using the following guidelines:

  • If the individual agrees with the addition, increase, decrease or termination of services, the case manager implements the change.
  • If the individual does not agree with the addition or increase of services from the UR finding, the case manager does not implement the change. The case manager must document in the case record and on the UR tool why the change was not implemented. If the individual’s decision places his health and welfare at risk, the case manager, in consultation with the regional nurse, must review the UR finding with the individual or primary caregiver to ensure the individual made an informed choice.
  • If the individual does not agree with the decrease or termination of services, the case manager must implement the UR finding.

 

10440 Exception to Implementing Termination/Decrease of Services from the Utilization Review Finding

Revision 12-3; Effective November 1, 2012

 

An exception to implementing the decrease or termination of services from the utilization review (UR) finding is allowable if the individual has experienced a change in condition or environment since the UR visit and the change in services would result in a risk to the individual’s health and welfare.

There may be instances where the individual’s or caregiver’s condition or circumstances change, without a threat to his health and welfare, since the UR visit and the individual's individual plan of care (IPC) must be revised to meet the current needs for waiver services or the primary caregiver’s need for respite. The case manager takes appropriate action to address the individual’s or primary caregiver’s current needs.

 

10450 Notifications

Revision 13-2; Effective May 1, 2013

The case manager completes Form 2065-B, Notification of Waiver Services, for reductions, addition or increase in services and Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for program terminations. The case manager must also update or complete applicable service authorization forms. The case manager documents the effective date of the individual plan of care change 30 days from the date of the notification form for service reductions or program terminations. The case manager documents the appropriate handbook/rule citation and also adds a comment to the notification form that the decision is based on the utilization review finding, as appropriate for the change.

If the applicant/individual requests a fair hearing, the case manager must inform the utilization review (UR) nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR findings. The case manager must follow policy in Section 9611.3, Procedures for Utilization Review Findings, when processing the request for a fair hearing.