ACCESS & AUTHORIZATION

HOUSEKEEPING Food Restrooms Cell phones and calls Questions

INTRODUCTION Purpose of today Processes that will be touched on today but covered in detail at subsequent training Process for authorizing current SUD service individuals

ACCESS Requests for Service (RFS) The day the individual requests services/assessment by calling, walking in, written request Can’t refuse to serve individuals who are challenging to serve No Wrong Door Centralized Access Line BHA directly NSBHO Policy 1503

ACCESS RFS to VOA Centralized Access Line ( ) VOA screens Transfer of phone call to BHA to schedule assessment VOA to BHA with RFS information VOA transmits RFS information to NSBHO

ACCESS RFS to BHA Call or walk in directly to Behavioral Health Agency (BHA) BHA screens BHA transmits RFS information to NSBHO

ACCESS Financial Eligibility Washington Apple Health with BHO benefit State funding priorities Substance Abuse Block Grant funding priorities Referrals if not eligible

ACCESS State funding priorities Mental Health (at or below poverty guidelines) Western State Hospital (WSH), Children’s Long- Term Inpatient (CLIP) Less Restrictive or Conditional Release Court Order Spenddown (not at RFS)

ACCESS State funding priorities Substance Use (at or below 220% of Federal Poverty Guidelines) Pregnant and Parenting Women (PPW) Individuals Using Intravenous Drugs (IUID) Youth without insurance Spenddown (not at RFS)

ACCESS SABG funding priorities (at or below 220% of Federal Poverty Guidelines) PPW, IUID, Youth without insurance

ACCESS Handling a RFS requires: Financial screening Gathering demographic and contact information

ACCESS Handling a RFS requires (cont): Determine type of assessment appointment Standard, expedited, hospital discharge, outreach Determining need for interpreter and/or special accommodation Ensuring appropriate consents are obtained prior to assessment as needed

ACCESS Handling a RFS requires (cont): Need for crisis appointment prior to assessment (e.g., risk of harm) Safety planning for assessment as applicable Identifying need for APS or CPS report as applicable

ACCESS Handling a RFS requires (cont): Referral to MCO if appropriate (mental health services)

ACCESS Same Day assessment appointments RFS is the day the individual requests services/assessment RFS information for scheduled vs. same day appointments Ensure prioritization of individuals with highest, most immediate needs

ACCESS Same Day assessment appointments Continued scheduling of some appointments Follow RFS protocol for scheduled appointment Scheduled appointment required by court Outreach Interpreter

ACCESS NSBHO Data Dictionary Transactions submitted by VOA or BHA Request for Service – 837P (5010) HIPAA transaction Request for Service – Additional Information transaction (905) Transaction submitted by BHA First Offered/Referral transaction ( )

ACCESS Assessment transactions BHA submits Assessment Information transaction (906) if assessment does not occur Substance Use transaction (911) if applicable

ACCESS Assessment - Clinical Eligibility Access to Care Standards Covered diagnoses (DSM-5 and ICD-10) Functional impairment ASAM (American Society of Addiction Medicine) Criteria for SUD Serious Emotional Disturbance/Serious Mental Illness for MH BHA recommends authorization or denial Assistance to individual with referrals and linkages if recommending denial NSBHO Policy 1504

DENIAL Submit denial request to NSBHO via secure Denial Review Request form Assessment Additional collaborative documentation as indicated on the form NSBHO Policy 1505

DENIAL NSBHO makes determination Notification to individual and BHA Denial – process complete Authorization – additional steps

AUTHORIZATION BHA completes Level of Care ASAM Criteria - SUD 909 transaction CA/LOCUS (Child & Adolescent/Level of Care Utilization System) – Mental health 845 transaction (LOCUS), 846 transaction (CALOCUS)

AUTHORIZATION LOC updates Do not require new authorization MH LOC 1 and 2 – Minimum of annually LOC 3 and up - Minimum every 6 months SUD All LOC - Minimum every 6 months LOC must be updated at other times when individuals experience changes that would impact their LOC NSBHO Policy 1565

AUTHORIZATION BHA requests authorization Authorization Request 278 HIPAA transaction 278 transaction that corresponds with mental health or substance use Additional Authorization Information transactions Additional Authorization Information transaction 951 transaction for mental health 952 for substance use

AUTHORIZATION NSBHO provides response via 278 Services authorized BHA transaction did not have sufficient information to authorize Notification to individual Services may be denied BHA notified to follow denial process

AUTHORIZATION NSBHO authorizes services BHA opens outpatient episode Submits Omnibus Episode Information transaction (902) BHA submits First Routine Appointment transactions 907 (always) and 908 (if appointment did not occur) 911 as applicable for SUD per required timelines

AUTHORIZATION BHA provides services BHA submits encounters per Service Encounter Reporting Instructions Authorization is for all covered, medically necessary services with exception of SUD Residential

AUTHORIZATION SUD Residential Residential indicated per ASAM Criteria Outpatient BHA locates Residential facility and coordinates admission Outpatient BHA requests authorization on behalf of Residential facility Residential facility responsible for submitting encounter data

AUTHORIZATION SUD Residential (cont) Outpatient BHA provides medically necessary outpatient services until Residential available ASAM update if individual waiting for residential bed longer than 30 calendar days Outpatient BHA participates in treatment and discharge planning with Residential NSBHO Policy – to be written

AUTHORIZATION Authorization periods Services need to be medically necessary to continue during an authorization period Authorization not terminated when episode of care ends Individual may have multiple episodes of care during an authorization period

AUTHORIZATION Authorization periods Mental Health LOC 1 and 2 – 6 month authorization LOC 3 and up – 1 year authorization State funding – 3 month authorization Substance Use LOC 0.5 through 2.1 – 1 year authorization LOC 3.1 (Recovery House Residential) – 90 days LOC 3.3 (Long-term Residential) – 30 days LOC 3.5 (Intensive Inpatient Residential)– 15 days

REAUTHORIZATION Recovery/Resiliency Plan (aka Individual Service Plan) Review complete Within 45 days of current authorization end date Transaction 930 Level of Care is current Episode of care is open

REAUTHORIZATION Transactions Authorization Request 278 HIPAA transaction Additional Authorization Information transaction (951)

ADDITIONAL NEEDS IDENTIFIED Behavioral health service available within BHA Update assessment, authorization, episode of care information via transactions Behavioral health service available at another NSBHO-contracted BHA NSBHO Policy 1510 Out of Network services NSBHO Policy 1522 Medical or other allied system services

DISCHARGE Discharge plan Update Omnibus Episode Information transaction (902) Consumer Periodics transaction (035.06) Update Substance Use transaction (911) if applicable NSBHO Policy 1540

Q&A Flow chart handout NSBHO Policies OC.aspx OC.aspx Data Dictionary

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