Medicaid Managed Care Council
Behavioral Health Oversight Committee
Legislative Office Building
Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-0023
of Care Work Group Recommendations
Patient continued access to care during conflict of
medical/behavioral health primary diagnosis: If the MCO & ASO are unable
to “reach a timely resolution and/or refer the matter (conflicting
determination as to whether medical or behavioral health is primary) to DSS, the
entity (that initially authorized) the request must provide authorization until
the matter is resolved.”
WG 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).
Define time lines for prior authorization (PA) and continuity
The Work Group recommended
The timelines in the 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.
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.
Standard information required of providers for authorization:
Providers are generally aware of the level of information needed for
‘medically necessary’ psych inpatient authorization/continued
hospitalization. However, information required of providers beyond what is
“standard” for a level of care could result in an authorization delay when a
provider cannot or does not comply with what may perceived by the provider as an
arbitrary request for additional information. Given there will be practice
guidelines developed, the WG recommended the agencies and ASO:
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
Include the Medicaid definition of “medical necessity”
for material documenting appropriate levels of care.
Dispute Resolution Process
There were two issues noted, with the example of a
dispute occurring in off-hours:
The hospital/ED believes hospitalization is appropriate, but this level
of care is denied by the MCO and 2) the parent of a child in a BH crisis
disagrees with discharge from hospital/ED to community level of care because of
concern about the safety of having the child/youth at home.
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.
DSS establish a telephonic immediate appeal process with the
The discussion focused on approvals of temporary drug
supplies when there is no prior authorization for non-formulary and/or formulary
drugs that require such authorization initiated by the prescribing provider.
Pharmacy reports to the Medicaid Council show significant variation among
HUSKY MCOs in providing temporary drug supplies.
The DSS stated they have been working with the MCOs on resolving the
deficits in consistently applying the DSS policy.
The WG recommended:
o That the DSS & MCOs come to a resolution of this issue prior to the implementation of the BH restructuring.
o The DCF provide information to the WG on the psychotropic drug denials for their clients.
o The DSS provide a report on frequency of medication rejection at the pharmacy (client leaves without the script being filled).
o DSS provide a report on any mental health drugs excluded from the MCO formularies.
5/3 WG update:
Reimbursement for hospital stays during which the diagnosis
changes from primary medical to psychiatric under the ASO/MCO management:
The Work Group suggested:
The DSS/DCF discuss this reimbursement issue further with
hospitals to ensure there is an appropriate process in place, based on the flow
The timeliness of transfer of patients from medical to
psychiatric services upon diagnosis change should be monitored within the ASO.
Primary Care BH referral assistance:
The Work Group recommended that the departments add 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.
Ø Primary Care Provider notification of their patient’s BH services. The work group recommended that the departments clarify the role of the ASO in notifying PCPs in contract language.
5/3 WG Meeting update: families have agreed that the integration of medical & BH system is important, providing a process for written consent for BH service information to be shared with the PCP. The departments suggested some possible vehicles for this within the ASO.
Coordination of MCO/ASO Case Management:
The work has reviewed the work flow chart provided by the agencies.
One suggestion was that the ASO directly contact the DCF Health Advocate
for DCF children. (see attached work flow sheet reviewed at the Care
coordination WG and the DCF Work Group).
with MCO & ASO for BH services – 5/3/05
Transportation to BH services, the responsibility of the MCOs, does
affect access to services. The
Transportation access be a focus area for monitoring in the 1st
year of the carve-out.
Identify specific questions related to transportation access
for the BH member satisfaction survey.
The HUSKY transportation information grid was reviewed again at
the Medicaid Council Consumer Access meeting 5/4/05: 1) clarified that the
provider identify the “reason” for special transportation services, rather
than using term “medical reason”, 2) will request information from MCOs on
provider arrangements for ongoing multiple week services for BH and 3) clarified
that special transportation for members with BH special needs can be requested
by the MH provider.