INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT QIO Request Submission Requirements for Community Support Services New 6/14/2012

Topics Services Requiring PA KEPRO SCDHHS Website Service Type Requirements Contact Information

Prior Authorization Services Adult (22 years old and older) H2017-Psychosocial Rehabilitation Service (PRS) S9482-Family Support Child (21 years old and younger) H2017-Psychosocial Rehabilitation Service (PRS) H2014-Behavioral Modification S9482-Family Support

Forms Navigate to Forms TAB to obtain Documents

Outpatient Fax Form

Adult H2017 (PRS) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) For Continuation of Services- Individualized Plan of Care (IPOC) Service Plan Development Note 90 Day Progress Summary

Adult H2017 (PRS) Criteria For Initial Services, beneficiary must: –Diagnosed with a serious or persistent mental illness which includes one of the following: Schizophrenia, Bipolar Disorder, Major Depression, Psychotic Disorder NOS, or Schizoaffective Disorder –Moderate or severe functional impairment that interferes with 3 or more of the following: Daily living Personal Relationships Work Setting School Setting Recreational Setting

Adult H2017 (PRS) Criteria For Initial Services, beneficiary must: Meet Three or more of the following criteria as documented in the DA: –Is not functioning at a level that would be expected of typically developing individuals their age; –Is at risk of psychiatric hospitalization or out-of home placement –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –In the last 90 days exhibited behavior that resulted in at least one intervention by crisis response, social services, or law enforcement. The services is recommended by an independently LPHA acting within the scope of his/her professional licensure The service, including frequency of the service, is recommended as result of the DA Beneficiary is expected to benefit from the intervention and needs would not better clinically met by any other formal or informal system or support

Adult H2017 (PRS) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC and a revised plan addresses service modifications to address remaining issues; –Beneficiary continues to be at risk for out-of home-placement; –The family/caregiver is actively engaged in the treatment process, which is clearly documented in the clinical record –Beneficiary continues to meet medical necessity criteria ***Please submit for continuation of services no more than 10 business days prior to the end of your current authorization

Adult (Family Support) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) For Continuation of Services- Individualized Plan of Care (IPOC) Service Plan Development Note 90 Day Progress Summary

Adult S9482 (Family Support) Criteria For Initial Services, beneficiary must: –Beneficiary has been diagnosed with a serious and persistent mental illness (SPMI) which includes one of the following: Schizophrenia, Bipolar Disorder, Major Depression, Psychotic Disorder NOS or Schizoaffective Disorder; or co-occurring SPMI and substance use disorders (SUD) –Demonstrates moderate to severe functional impairment in 3 or more of the following areas as result of SPMI and/or SUD: Daily Living Relationships School Work Setting Recreational Setting –Family or Caregiver agrees to be an active participant, which involves participating in interventions

Adult S9482 (Family Support) Criteria For Initial Services, beneficiary must : Meet Three or more of the following criteria as documented in the DA: –Is not functioning at a level that would be expected of typically developing individuals their age; –Is at risk of psychiatric hospitalization or out-of home placement –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –In the last 90 days exhibited behavior that resulted in at least one intervention by crisis response, social services, or law enforcement. The Family or caregiver agrees to be an active participant (if family or caregiver is unable or unwilling to be an active participant, this must be clearly documented). The services is recommended by an independently LPHA acting within the scope of his/her professional licensure The service, including frequency of the service, is recommended as result of the DA Beneficiary is expected to benefit from the intervention and needs would not better clinically met by any other formal or informal system or support

Adult S9482 (Family Support) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC and a revised plan addresses service modifications to address remaining issues; –Beneficiary continues to be at risk for out-of home-placement; –The family/caregiver is actively engaged in the treatment process, which is clearly documented in the clinical record –Beneficiary continues to meet medical necessity criteria ***Please submit for continuation of services no more than 10 business days prior to the end of your current authorization

Child H2017 (PRS) Submission Requirements Please submit to KEPRO : For initial services- Diagnostic Assessment (DA) Parenting Stress Index (PSI) – Birth to 1.5 years Child Behavior Check List – 1.5 to 5 years CALOCUS – 6 years and older Parent/Guardian Agreement Form (Birth to 15 years) For Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child H2017 (PRS) Submission Requirements Providers rendering services to children being referred by state agency: Submit to KEPRO for Initial Services- Rehabilitative Behavioral Health Services (RBHS) Referral Form Parent/Guardian Agreement Form (Birth to 15 years) Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child H2017 (PRS) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-6) has been diagnosed with a serious emotional disorder (SED) or an applicable Z code as per the current DSM; OR –Beneficiary (ages 7-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Moderate to severe functional impairment that interferes with performance in 3 or more of the following areas: –Daily living –Personal Relationships –School –Work Setting –Recreational Settings

Child H2017 (PRS) Criteria For Initial Services, beneficiary must (cont’d): Meet Three or more of the following criteria as documented in the DA: –Is not functioning at a level that would be expected of typically developing individuals their age; –Is at risk of psychiatric hospitalization or out-of home placement –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –In the last 90 days exhibited behavior that resulted in at least one intervention by crisis response, social services, or law enforcement. The Family or caregiver agrees to be an active participant (if family or caregiver is unable or unwilling to be an active participant, this must be clearly documented). The services is recommended by an independently LPHA acting within the scope of his/her professional licensure

Child H2017 (PRS) Criteria For Initial Services, beneficiary must (cont’d): The service, including frequency of the service, is recommended as result of the DA and the score on the age appropriate tool Beneficiary is expected to benefit from the intervention and needs would not better clinically met by any other formal or informal system or support The score on the age appropriate assessment tool indicates need for service –Birth-1.5 years, has scored in the 81 st percentile or above on the Parenting Stress Index (PSI) –1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65) on at least one syndrome scale and one DSM-Oriented Scale of The Child Behavior Check List –6-21 years, has been assigned a minimum CALOCUS composite score of 17

Child H2017 (PRS) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC; –Beneficiary continues to be at risk for out-of home-placement; –For child and adolescent beneficiaries: The family/caregiver/guardian is actively engaged in the treatment process, which is clearly documented in the clinical record –Beneficiary continues to meet medical necessity criteria. ***Please submit for continuation of services no more than 10 business days prior to the end of your current authorization

Child H2014 (Behavioral Modification) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) CALOCUS, Parenting Stress Index or Child Behavior List Parent/Guardian Agreement Form (Birth to 15 years) For Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child H2014 (Behavioral Modification) Submission Requirements Providers rendering services to children referred by state agencies only Submit to KEPRO for Initial Services- Rehabilitative Behavioral Health Services (RBHS) Form Parent/Guardian Agreement Form (Birth to 15 years) Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child H2014 (Behavioral Modification) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-6) has been diagnosed with a serious emotional disorder (SED) or an applicable Z code as per the current DSM; OR –Beneficiary (ages 7-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Engaging in behaviors in 1 or more of the following behaviors: physical aggression, verbal aggression, object aggression, self-injurious behavior and presents risk of harm to self or others and significantly impact functioning in 3 or more of the following areas as documented on the Diagnostic Assessment: Daily Living Relationships Work Setting School Setting Recreational Setting

Child H2014 (Behavioral Modification) Criteria For Initial Services, beneficiary must (cont’d): Meet Three or more of the following criteria as documented in the DA: –Is not functioning at a level that would be expected of typically developing individuals their age; –Is at risk of psychiatric hospitalization or out-of home placement –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –In the last 90 days exhibited behavior that resulted in at least one intervention by crisis response, social services, or law enforcement. The Family or caregiver agrees to be an active participant (if family or caregiver is unable or unwilling to be an active participant, this must be clearly documented). The services is recommended by an independently LPHA acting within the scope of his/her professional licensure

Child H2014 (Behavioral Modification) Criteria For Initial Services, beneficiary must (cont’d): The service, including frequency of the service, is recommended as result of the DA and the score on the age appropriate tool Beneficiary is expected to benefit from the intervention and needs would not better clinically met by any other formal or informal system or support The score on the age appropriate assessment tool indicates need for service –Birth-1.5 years, has scored in the 81 st percentile or above on the Parenting Stress Index (PSI) –1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65) on at least one syndrome scale and one DSM-Oriented Scale of The Child Behavior Check List –6-21 years, has been assigned a minimum CALOCUS composite score of 17

Child H2014 (Behavioral Modification) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC; –Beneficiary continues to be at risk for out-of home-placement; –For child and adolescent beneficiaries: The family/caregiver/guardian is actively engaged in the treatment process, which is clearly documented in the clinical record –Beneficiary continues to meet medical necessity criteria. ***Please submit for continuation of services no more than 10 business days prior to the end of your current authorization

Child S9482 (Family Support) Submission Requirements Please submit to KEPRO: For initial services- Diagnostic Assessment (DA) CALOCUS or Child Behavior Check List Parent/Guardian Agreement Form (Birth to 15 years) For Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child S9482 (Family Support) Submission Requirements Providers rendering services to children referred by state agency: Submit to KEPRO for Initial Services- Rehabilitative Behavioral Health Services (RBHS Referral Form) Parent/Guardian Agreement Form (Birth to 15 years) Submit to KEPRO for Continuation of Services- Individualized Plan of Care (IPOC) 90 Day Progress Summary Service Plan Development Note Parent/Guardian Agreement Form (Birth to 15 years)

Child S9482 (Family Support) Criteria For Initial Services, beneficiary must: –Beneficiary (ages 0-6) has been diagnosed with a serious emotional disorder (SED) or an applicable Z code as per the current DSM; OR –Beneficiary (ages 7-21) has been diagnosed with a serious emotional disorder (SED) or a co-occurring SED and substance use disorder (SUD) –Demonstrates moderate to severe functional impairment in 3 or more of the following areas: Daily Living Relationships School Work Setting Recreational Setting

Child S9482 (Family Support) Criteria For Initial Services, beneficiary must (cont’d): Meet Three or more of the following criteria as documented in the DA: –Is not functioning at a level that would be expected of typically developing individuals their age; –Is at risk of psychiatric hospitalization or out-of home placement –Experiences impaired cognitive ability to recognize personal or environmental dangers or significantly inappropriate social behavior. –In the last 90 days exhibited behavior that resulted in at least one intervention by crisis response, social services, or law enforcement. The Family or caregiver agrees to be an active participant (if family or caregiver is unable or unwilling to be an active participant, this must be clearly documented). The services is recommended by an independently LPHA acting within the scope of his/her professional licensure

Child S9482 (Family Support) Criteria For Initial Services, beneficiary must (cont’d): The service, including frequency of the service, is recommended as result of the DA and the score on the age appropriate tool Beneficiary is expected to benefit from the intervention and needs would not better clinically met by any other formal or informal system or support The score on the age appropriate assessment tool indicates need for service –Birth-1.5 years, has scored in the 81 st percentile or above on the Parenting Stress Index (PSI) –1-.5 – 5 years, has scored in the borderline to clinical range (minimum T score of 65) on at least one syndrome scale and one DSM-Oriented Scale of The Child Behavior Check List –6-21 years, has been assigned a minimum CALOCUS composite score of 17

Child S9482 (Family Support) Criteria For continuation of services: –The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame identified in the IPOC; –Beneficiary continues to be at risk for out-of home-placement; –For child and adolescent beneficiaries: The family/caregiver/guardian is actively engaged in the treatment process, which is clearly documented in the clinical record –Beneficiary continues to meet medical necessity criteria. ***Please submit for continuation of services no more than 10 business days prior to the end of your current authorization

Retroactive Medicaid Eligibility A case may be submitted as a “retro” when retroactive Medicaid eligibility occurs or when Medicaid becomes the primary payer This includes : Member not eligible for coverage at the time services were provided. Member gains eligibility that is made retroactive to the date of service. NOTE** A “retro” case is NOT one that is submitted late for any reason.

KEPRO/Provider Turnaround Time KEPRO Upon receipt of PA request, KEPRO must render a decision within 5 business day of the request submission (excluding higher level reviews) If the PA request is submitted for higher level review, KEPRO has 1 additional day to render a decision. Provider If additional information is required for review, the request will be pended, and the Provider will have 2 business days to submit the additional information required to KEPRO.

Registration for Atrezzo Connect Provider Portal INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

How To Register For Atrezzo Connect Website Address: Select “ Registration For Atrezzo Connect” (Slide 3) Enter your 10 digit National Provider Identifier (NPI) number and Legacy South Carolina Medicaid provider ID Select a unique user name and password & complete required user information

Atrezzo Connect Atrezzo Connect allows for: – Secure access to Atrezzo Connect (Provider Portal) – Provider will be able to access letters by Case/Request, Respond/Send messages To/From KePRO

Required Information for Security Verification The provider must enter information to verify authenticity for security reasons Registration Code: – SCDHHS Legacy ID

Simple -5 Step Registration Process Start by clicking the Atrezzo Login button on the SCDHHS-KEPRO website

Login Page You will be brought to this login page

Step 2 – Enter NPI and Legacy ID Enter your organization’s NPI number and Legacy Provider ID = Provider Registration Code Click NEXT

Step 3 – Terms of Agreement Review Terms of Agreement. Upon acceptance, you will be taken to setup for User information.

Step 4 – Verify Address Click on the correct address(s) for the new account (this associates your user information with these locations) If all apply, check all of them Click SELECT

Step 5 – Enter Account Information Enter user account information User Name, Password, First/Last Name, and Fax Number are required fields! Click NEXT-This will take you to the Password setup and security question Slide) Passwords do not expire. Minimum 8 characters required.

Successful Completion Successful Completion of setup, takes you to the Home Page

View all request and Create new request Click Member to search using Member id or Last name/DOB Click Request/Case to search using Case id, Member info or Request info

Create Preferences, Manage User accounts and New Provider Registration Use this tab to change your password or update your contact information View Atrezzo User Guide and View FAQs

Account Administrator All information submitted for registration under Provider/Facility Information will represent as the Provider Portal Administrator (Group Admin). The Group Admin is responsible for managing and creating all Submitting User accounts for your NPI # – Create other Group Admins’ & Admin Users – Set Preferences, i.e. Diagnosis and Procedure codes, etc

KEPRO Contacts

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