Behavioral Health Partnership Oversight Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-5306
Coordination of Care Subcommittee
Meeting Summary: September 30, 2005
Chair: Sheila Amdur
Attendees: S. Amdur, K. Diamond(Anthem), R. Ciarcia, M.Schaefer (DSS), K. Colvin (CHNCT), A. Kamm (DCF), Dr. R. Walia, C. Montesi (PONE), M. MCCourt (Staff).
Status of Work Group Recommendations in Coordination of Care Document
Below are the original recommendations from the Work Group with “Outcome” referring to the action by the BHP agencies.
ü The MCOs will identify BH NEMT data versus medical NEMT data in their NEMT reporting to DSS as a baseline measure.
Outcome: Developing a reporting measure to go forward. There is no available bench mark data by service type.
ü Going forward, DSS will collect BH vs. non-BH NEMT data comparable to the baseline data indicators.
ü Transportation-specific questions will be included in the client satisfaction surveys going forward.
Outcome: Client satisfaction survey questions, which will include transportation questions, will be developed by families & ASO after January, 2006.
ü DSS will collect any NEMT complaints from the ASO.
Outcome: process for transportation complaints:
o Complaint first goes to the MCO, responsible for transportation services
o Persistent problems and or problems that directly affect BH care should be brought to the ASO.
o ASO and MCO work together to solve the problem
Ø Independent Evaluation of the BH KidCare Program
Under the waiver amendment, CMS will not require an evaluation of the program by an External Quality Review Organization (EQRO). The DSS stated they would be adding a BH evaluation component to the Mercer HUSKY quality evaluation. The Work Group stressed the importance of program evaluation by an independent contractor that currently does not have a contract with DSS or DCF.
Work Group Recommendation:
ü There be an ongoing independent impartial comprehensive evaluation of the BH program by an expert entity that has no contracts with CT State agencies, managed care organizations or the ASO.
ü The BH Oversight Committee, along with DSS and DCF, have input into the development of the evaluation process and review of the evaluation reports.
o Funding for an independent evaluation of the program will need to be requested in the state budget in 2006 session.
o DCF has dollars to evaluate KidCare
o RWJ grant to develop performance measurements (the Quality Subcommittee is working on this).
The four HUSKY A and three HUSKY B managed care organizations will continue to be responsible for pharmacy services in HUSKY A and HUSKY B.
The Work Group recommended the following, with the goal of preventing parents of children with MH diagnoses or adults with MH diagnoses leaving the pharmacy without the prescribed medication:
ü Additions to the current MCO pharmacy reports to DSS that would be available no later than Oct 1 2005:
o Monthly reports by each MCO of the total number of rejections due to lack of PA.
o The number of the rejected authorizations that have NO temporary drug issued within 24 hours.
o The class of the drugs tied to the rejections.
ü A provisional recommendation was made that would be implemented if the above data suggests the need for such implementation:
o In conformance with state Medicaid fee-for-service policy, at a minimum, all mental health drugs that require PA have a temporary supply automatically authorized at the pharmacy for any mental health drug prescription rejected because of lack of prior authorization.
Status to date:
o DSS has worked with Anthem and Health to add electronic message at the pharmacy when scrip rejected regarding temporary supply under Medicaid. Ready in early September.
o ASO has offered to do biannual pharmacy analysis
o Covering Kids projects developed a quick look PA guide, which will be mailed to pharmacists. DSS requested to share with DCF, MCOs (who could share with their providers) and the Medicaid/BHP Council.
o Further recommendation: Medicaid Fee-for-service policy on drug authorizations apply to MCO process.
Ø Emergency Department (ED) visits
Emergency Care remains within the MCO responsibility. The work group recommended that there be a process developed by which the ASO will be informed of BH ED visits in a timely manner. DSS will be reviewing this with the MCOs in the near future.
o For the 23- hour BH observation, the BHP will pay.
o ED Stays over 24 hours will be paid by BHP.
o Other urgent/emergent visits are responsibility of the MCO.
o The ASO will be tracking extended ED stays, involve their care manager to move the patient out of the ED to appropriate level of BH care.
Ø Patient continued access to care during conflict of medical/behavioral health primary diagnosis:
Recommendation: add in ‘admission’ and ‘concurrent’ reviews section “All times are measured from the time the Contractor receives all information deemed reasonably necessary. (DSS added this in the document DETERMINATION OF PRIMARY DIAGNOSIS SUMMARY after the meeting).
Ø Define time lines for prior authorization (PA) and continuity of care
o 1) The timelines in the BH RFP be adopted in the ASO contract: decision for PA communicated to the provider by telephone within 60 minutes of the request for hospital admission, PHP, IOP, inpatient detox. 2) Concurrent reviews decision within 60 minutes or before 5 PM. The decision for all other service concurrent review requested by the provider shall be made within 2 business days of the request.
o 1) Inpatient, PHP, IOP, inpatient detox PA decisions made within one hour.
o 2) Concurrent review decisions made same day.
o Exception would be decisions that involve peer review process, to be resolved in 2 business days.
Ø Standard information required of providers for authorization
The WG recommended the agencies and ASO:
o Develop standard information per level of care that identify specific indicators for that level of care, thereby including the provider as a partner in working with the family and ASO to secure the appropriate level of care.
o Include the Medicaid definition of “medical necessity” for material documenting appropriate levels of care.
o The level of care guidelines developed by the Provider Advisory subcommittee and approved by the BHP Council outline information required by the PA.
o No denials will be issued with the provider offered the opportunity for a peer review process within one business day of the denial.
o Decisions will be based on care guidelines, Medicaid medical necessity and outcome of peer review process.
Ø Dispute Resolution Process
o DSS establish a provisional authorization process for 24 hours, determined on a case-by-case basis, which allows family to be connected to community collaboratives, EMPS and other needed services.
o DSS establish a telephonic immediate appeal process with the authorization entity
o Peer review with the clinician in one hour.
o BHP ask VOI to describe provisional authorization policy/procedures.
Ø Reimbursement for hospital stays during which the diagnosis changes from primary medical to psychiatric under the ASO/MCO management:
o The DSS/DCF discuss this reimbursement issue further with hospitals to ensure there is an appropriate process in place.
o The timeliness of transfer of patients from medical to psychiatric services upon diagnosis change should be monitored within the ASO.
Outcome: Hospital will bill the BHP and the MCO . BHP and VOI are still looking to identify process to ensure and capture timely transfer of patient from medical to BH services.
Ø Primary Care BH referral assistance
The Work Group recommended that the departments add language to the ASO contract that the ASO will offer appointment assistance to members either at the time of the request for BH network referrals of when the member calls back with further assistance needs.
Outcome: Added to the contract provisions.
The Coordination Work Group will no longer meet. Monitoring of recommendations will be part of the Quality Management and Access Subcommittee and other subcommittees as deemed necessary by the BHP Oversight Council.
Sheila Amdur thanked the agencies and participants for their diligent and work and looks forward to continued work on these recommendations through the other subcommittees.