Treatment Plans, Notifications and Authorization Requirements

Q:         Do I have to seek preapproval to provide services to patients enrolled in Medicaid?

A:         Providers are required to notify MCOs when a MCO-enrolled individual seeks treatment.   Although preapproval is not required, there are requirements for on-going authorizations for most of the self-referred services.  The outlines the notification and authorization requirements, specifying the provider communication responsibilities, the MCO/BHO communication responsibilities and the approval criteria for Medicaid covered treatment services.  All substance abuse providers should carefully review and implement these protocols.

Q:         Can I just use the Treatment Plan required by MCOs through the SAII?

A:         The Treatment Plans or forms currently included in the SAII do not meet all the requirements of ADAA.  There may be an effort to change these treatment plans to make them consistent with the minimum requirements of ADAA.  Until that happens, most MCOs have indicated that they are willing to accept a note on the SAII forms and a copy of treatment plan from the patient record.

Q:         Does the requirement that a licensed professional sign off on the assessment need to be documented in the clinical treatment plan that we put in the patient record or to the Uniform Treatment Plan that is required by the MCO's? Also does the requirement apply only to the initial treatment plan or also to revisions to treatment plans? 

A:         The requirement that a licensed professional sign-off on the treatment plan relates to billing for Medicaid covered services.  Therefore this sign-off requirement applies to the MCO Uniform Treatment Plan, both the initial treatment plan and concurrent treatment plan. The “concurrent treatment plan” is the MCOs’ term for the revised treatment plan that is submitted after the patient has been in treatment for awhile.  In addition, the provider should place a copy of this sign-off in the patient’s record so that they will have documentation for state and federal audits.   

Q:         We have a couple of treatment tracks available for clients based on the results of the Comprehensive Assessment.  There is a less intensive track that fits within the 30 sessions per calendar year provision.  There is also a more intensive track that exceeds this threshold?  Is it possible to request additional services (beyond 30) with the submission of the Initial Treatment Plan?

A:         The 30 session per calendar year has to do with the for ASAM Level 1 Outpatient Services.  It is not a benefit limitation.  If the patient requires additional medically necessary services, the provider needs to request a pre-authorization from the patient’s MCO.  

It may not be possible to tell in advance whether the patient will need a more or less intensive set of services.   This information should be included in your initial your treatment plan if you know, but the MCO could still evaluate the medical necessity when the 30 sessions is up.   Is this necessary – it is so vague – isn’t the point that it is up to the MCO, ask if you want.

Q:         If a patient has been authorized for 30 visits, would 2 services in the same day count as 2 visits of the 30?

 

A:         Yes.