Field Utilization Review Waiver/Community Services UR Utilization Management and Review (UMR) Access and Intake DADS

Mandates 2010-2011 General Appropriations Act, Article ll, Rider 36, SB 1. 2012-2013 General Appropriations Act, Article II, Sec. 56b. Mandates the use of utilization management and utilization review practices as necessary to ensure that the: appropriate scope and level of services are provided to individuals receiving services in Medicaid 1915(c) waivers administered by the department, and ensure compliance with the cost-effectiveness requirement of Centers for Medicare and Medicaid Services (CMS).

Process face-to-face visit with the individual based on statewide, statistically valid, random sample of individuals currently enrolled in the identified program

Field UR Implemented Started FY ‘09 Community Based Alternatives (CBA) (Will be transferred to HHSC FY ‘15) Medically Dependent Children Program (MDCP) (Will be transferred to HHSC FY ‘16) Primary Home Care (PHC) (Will be transferred to HHSC FY ‘15) Started FY ‘13 Community Living Assistance and Support Services (CLASS) Home and Community Services (HCS) Texas Home Living (TxHmL) Starting FY ‘14 Deaf Blind with Multiple Disabilities (DBMD)

FY 2013 Sample Size Program Concurrent Total 1081 1109 CLASS 347 HCS 379 TxHmL 355 Total 1081 CBA 372 MDCP 356 PHC 381 1109

Field UR Staff State Office Four Regional Office Managers San Antonio (covers Regions 6 and 8) Paris (covers Regions 4 and 5) Weslaco (covers Regions 7 and 11) Abilene (covers Regions 1,2,3,9 and 10) Each office employs Registered Nurses who perform the utilization reviews.

Sample Selection The sample is based upon a statewide, statistically valid, random selection The sample is determined from the list of individuals currently enrolled in the identified program The sample is proportionate to the number of individuals served in each region

The UR Assessment Includes: Record Review: encompasses one year of service provision. The documentation request may go back further than one year if necessary. Interview and observation: a face-to-face visit with the individual, primary caregiver, nurses, attendants, therapists and others as appropriate. Contact will be made with the provider, service coordinator, and FMSA as applicable.

What Process Should Service Coordinators and Provider Staff Expect? UR nurse: Reviews the HCS/TxHmL CARE information Notifies the service coordinator Submits a fax request to the service coordinator for the required documents Conducts a desk review of faxed documentation Contacts service coordinator, individual and/or LAR to arrange face-to-face visit

Continued: Conducts face-to-face visit(s) Requests additional information or clarification as needed Presents results of UR to the Regional Unit Manager for evaluation of prospective findings and potential referrals Notifies the service coordinator of visit outcome

Continued: Faxes DADS Form 2067 to the service coordinator summarizing the findings that will affect the current IPC Accepts and reviews additional information from the service planning team Finalizes findings

Potential Outcomes: Based on the assessment the UR nurse may determine: The IPC is accepted as written, or A need to take one or more of the following actions: Add a service not currently authorized Increase a service Reduce a service Deny/End a service

Findings Resulting in IPC Change The UR Regional Manager submits the findings to the Central Office PE/UR staff The PE/UR staff will revise the authorized services and amounts in CARE if changes have not been made by the provider (HCS) or service coordinator (TxHmL). PE/UR staff notifies the individual of the right to appeal and faxes a copy of the notice to the Local Authority and provider.

Other Potential UR Actions A Referral to: 911 Adult Protective Services/Child Protective Services Consumer Rights and Services Office of Inspector General, Waste, Abuse and Fraud Individual Provider Solicitation Texas Board of Nursing Other

The initiation of UR was communicated to providers through the following information letters: CLASS, HCS, TxHmL, DMBD Information Letter No. 12-10 Implementation of Expanded Utilization Review Activities (January 25,2012) Information Letter No. 10-142 Expansion of Utilization Management and Review Activities (November 5, 2010)

Contacts Regions 1, 2, 3, 9, 10 Regions 4, 5 Regions 6, 8, 7(partial) Delio Herrera, UR Nurse Manager, 325-795-5594 Regions 4, 5 Cynthia Ukhun, UR Nurse Manager, 903-737-0235 Regions 6, 8, 7(partial) Alma Trevino, UR Nurse Manager, 210-619-8165 Regions 7, 11 Olga Reyna, UR Nurse Manager, 956-969-9281 State Office Susan Peterson, Unit Manager, 512-438-4105

Thank you!