Revision 17-1; Effective March 15, 2017

 

 

5100 Overview of Utilization Review

Revision 17-1; Effective March 15, 2017

 

Effective March 1, 2009, the Texas Health and Human Services Commission (HHSC) implemented processes for utilization review (UR) in the Community Care for Aged and Disabled (CCAD) Services.

The UR process for CCAD includes concurrent reviews of a random sample of individuals receiving:

  • Primary Home Care, and
  • Community Attendant Services (CAS).

A concurrent review is a UR of an ongoing service (not during the application process) and the cases are randomly selected for review.

 

5110 Concurrent Reviews of Randomly Selected Active Cases

Revision 17-1; Effective March 15, 2017

 

Concurrent reviews are conducted on a random sample of active cases in Primary Home Care and Community Attendant Services (CAS). The utilization review (UR) nurse will contact the case worker and request all or a portion of the documentation specified for reviews, and the case worker will provide the documentation within seven calendar days of the request. Depending on available information, the UR nurse may make a home visit and/or a Home and Community Support Services agency visit in addition to a desk review.

 

5200 Utilization Review Report to the Regions

Revision 17-1; Effective March 15, 2017

 

Concurrent utilization review (UR) may have findings or no findings to report to the region.

If there are any findings or information that needs to be relayed to the region, the UR manager will email the completed UR tool to the regional director (RD) or his designee. Upon receipt of a UR tool indicating an action is required in the Findings/Summary section of the UR tool, the region can either:

  • file an exception within five business days of receipt of the UR tool (See Section 5500, Utilization Review Exception Process, for guidelines); or
  • contact the assigned case worker and require the UR recommended changes be implemented.

If there are no findings, the UR nurse will contact the case worker via telephone or email to inform the case worker there were no findings. The UR tool will not be forwarded to the region and no documentation is required in the case record for a concurrent review with no findings.

 

5210 Other Utilization Review Reporting Processes

Revision 17-1; Effective March 15, 2017

 

The Utilization Review (UR) nurse managers will also inform the regional director within one HHSC workday if the following situations are identified during the course of any UR:

  • immediate threat to health or safety or medical emergency involving the individual;
  • risk or threat of danger to an individual;
  • abuse, neglect or exploitation of an individual;
  • violation of individual rights, problem with quality of services, potential fraud, or potential threat to health and safety; and
  • fraud, waste, and abuse of services. If indicated, the regional director will make a referral to the Office of Inspector General through established procedures and report the referral to the UR manager.

 

5300 Concurrent Review Process

Revision 17-1; Effective March 15, 2017

 

For a concurrent review with findings for Primary Home Care or Community Attendant Services cases, the Utilization Review (UR) nurse will contact the case worker and request the documentation for review, and the case worker will provide the documentation within seven calendar days of the request. Depending on available information, the UR nurse may make a home visit and/or a Home and Community Support Services agency visit in addition to a desk review.

If a concurrent UR results in a recommendation to decrease, increase or deny services, or identifies a policy compliance or quality of care issue, the case will be reviewed by the UR nurse manager. If the UR nurse manager concurs, he will email the UR tool to the Regional Director (RD) of the region where the individual resides. If the RD has a designee, only the baseline information and the findings will be sent.

The RD or designee will review the case and will contact the UR nurse manager, state office UR manager, or both, for any additional findings information needed. UR staff will immediately provide additional requested information to the RD.

The RD has seven business days following receipt of information from the UR manager to respond to the UR finding. During this time, the RD may:

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

If the RD attempts to contact the UR nurse manager by phone to discuss the findings in an informal exception process for a concurrent UR, and the UR nurse manager is not available, the UR nurse manager or designee will return the contact within two working days. If discussion (informal exception process) between the UR nurse manager and the RD 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 RD and case worker.

If the UR finding is not changed through the informal exception process and the RD 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 RD will notify the UR nurse manager via phone or email of the date the exception is filed.

If the RD agrees with the UR recommendation, within one HHSC workday, the RD will notify the UR unit of the agreement and direct the case worker to implement the UR finding.

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

 

5310 Implementation of Utilization Review Findings

Revision 17-1; Effective March 15, 2017

 

The regional director (RD) or designee will notify the case worker to implement the Utilization Review (UR) findings and will provide the date for completion and any specific instructions regarding the UR findings. The case worker files a copy of the findings page(s) and all service planning documents completed by the UR nurse in the case record to support justification for the changes made to the individual's services. Under no circumstances should the entire UR tool be filed in the case record.

The case worker follows the time frames and procedures below to implement the UR findings.

The UR findings for concurrent reviews must be implemented within 14 calendar days of:

  • the date the UR manager notifies the RD of the UR findings, unless a formal exception is made; or
  • the date state office issues a decision on a formal exception.

To implement the UR findings, the case worker may be required to increase, decrease, add or terminate services. The case worker follows current policy for changing service authorizations. This includes:

  • discussing the changes with the individual. For UR recommended changes to personal assistance services (PAS), the case worker must discuss the UR Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, tasks and allocated time changes with the individual;
  • documenting the discussion with the individual in the case record;
  • completing Form 2065-A, Notification of Community Care Services, documenting the action taken;
  • registering the change in the Service Authorization System (SAS), as applicable;
  • sending a copy of Form 2065-A to the individual; and
  • sending Form 2101, Authorization for Community Care Services, to the service provider.

The case worker must ensure all service criteria are met when completing the changes. The case worker must ensure the most current Form 2060 is entered in the SAS Functional Wizard and maintained in the case record.

 

5320 Individual Agreement or Disagreement with the Change

Revision 17-1; Effective March 15, 2017

 

The individual may agree or disagree with the Utilization Review (UR) findings when the case worker reviews the change request with the individual. The case worker completes the change action using the following guidelines:

  • If the individual agrees with the addition/increase or termination/decrease of services, the case worker implements the change.
  • If the individual does not agree with the addition/increase of services from the UR findings, the case worker does not implement the change. The case worker 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/or welfare at risk, the case worker, in consultation with the regional nurse, must review the UR findings with the individual or primary caregiver to ensure the individual made an informed choice. The case worker must follow procedures in Section 2550, Identifying Individuals at Risk, and Section 2551, Case Worker Actions for Individuals at Risk.
  • If the individual does not agree with the termination/decrease, the case worker must implement the UR findings. An exception to implementing the termination/decrease from the UR findings is allowable if the individual has experienced a condition or environmental change since the UR visit and the change would result in the individual's health and/or safety being jeopardized. The case worker must conduct an IDT meeting to review service needs and follow procedures for individuals at risk.

There may be instances where the individual's condition or circumstances have changed, without a threat to the individual's health and safety, since the UR visit and the individual's service plan must be revised to meet the needs of the individual. The case worker takes appropriate action to address the current needs, including reviewing personal assistance services hours or making a referral to the Home and Community Support Services provider for additional services, according to current procedures.

Advance notice must be given for any decisions that result in a reduction or termination of the individual's current services. The case worker documents the decision is based on "no unmet need for services" or "decreased need for service," as appropriate to the change. Refer to Form 2065-A, Notification of Community Care Services, instructions and Attachment A for denial reasons and appropriate comments.

 

5330 Provider Implementation of the Change

Revision 17-1; Effective March 15, 2017

 

Upon receipt of Form 2101, Authorization for Community Care Services, from the case worker, the service provider follows established procedures to implement the change request.

If the Home and Community Support Services (HCSS) provider has concerns about meeting an individual's needs based on the new service plan, the HCSS provider follows procedures outlined in Provider Information Letter (IL) 09-30, Implementation of Regional and Local Services (RLS) Utilization Review Program, dated Dec. 23, 2009, and IL 2007-06, Clarification of Licensing Rules and Contract Requirements Regarding Accepting Individuals with Complex Needs for Service, dated June 20, 2007.

Case workers follow current program enrollment policies, including conducting an interdisciplinary team meeting if needed, and assisting the individual with transferring to another provider when necessary.

 

5400 Reporting Implementation of the Utilization Review Findings

Revision 17-1; Effective March 15, 2017

 

After the case worker implements the Utilization Review (UR) findings, the region must complete the Completed by Region items in the Findings/Summary section of the UR tool to indicate the following:

  • Date of regional exception to SO: If applicable, enter the date the exception was sent to state office for review and decision.
  • CM action complete date: Enter the date the case worker completed the UR recommended change. This should be the date the change was entered in the Service Authorization System (SAS) and the notice was sent to the individual receiving services.
  • Effective date of action: Enter the date the UR change is effective. This should be the same effective date entered in SAS and on the notice to the individual receiving services.
  • Regional Comments/Reason for Exception: Enter any regional observations or conclusions. If an exception was filed, note the rule and policy basis for the exception, and the outcome of the state office review.

The completed UR tool must be returned by email to the referring UR unit manager within five business days of implementation of the UR recommended change. A copy of the Baseline Information and Findings page(s), not the entire tool, and all service planning documents completed by the UR nurse must be filed in the case folder.

 

5500 Utilization Review Exception Process

Revision 17-1; Effective March 15, 2017

 

If the regional director disagrees with the Utilization Review (UR) recommendation, he will refer the case via email and telephone within five workdays to the manager of the Community Care Services Eligibility (CCSE) unit at state office.

The state office CCSE unit manager will then make a final decision on whether to implement, revise or reverse the UR recommendation. The state office CCSE decision will be made within five workdays of the referral, and the state office CCSE unit manager will notify the regional director, the state office CCSE Regional Support and Program Implementation unit manager and the state office UR manager within one working day of the decision.

The region must implement the state office decision within 14 days of the region being notified of the decision.