Who needs to authorize a child's CFTSS treatment plan, DOH or the Medicaid Managed Care Plans?
Medicaid Managed Care Plans (MMCP) will be authorizing services for children enrolled in managed care. Each MMCP will develop a process by which providers will obtain authorization in line with the State issued utilization management guidelines. Specific MMCP processes for authorization can be found here.
Are you anticipating issues with MMCPs denying coverage if notification of the first 3 visits of OLP, PSR or CPST is not received either on a timely basis or at all?
No specific assessment tool needs to be completed for a child to access CFTSS; all that is needed is for the child to meet medical necessity criteria for the service.
Care Managers can refer directly to a CFTSS provider who is designated for OLP, for the non-physician licensed behavioral health practitioner to determine medical necessity for any CFTSS.
In addition, any licensed practitioner treating the child (such as their doctor) can make a recommendation to CFTSS by completing a written recommendation to document medical necessity based on clinical judgement.
Is there a standard form for notifying MMCP of CFTSS to be provided to children? Should providers anticipate some acknowledgement by the MMCPs that they received the notification? If no form, what does this notification look like?
There is no standard form for notifying plans prior to service delivery. Notification method/process depends on the MMCP.
What are the guidelines for authorization of Children's HCBS?
Authorization for continued services will entail a conversation between the MMCP and the HCBS provider, primarily. However, the Health Home Care Manager would notify the MMCP of the services. Continued authorization is between the HCBS provider and the MMCP.
How are Medicaid Managed Care Plans (MMCPs) notified of the first appointment date with each Children's HCBS provider?
As outlined in the policy, the first appointment is established with the HCBS provider. The HCBS provider reports the date of the first appointment to the MMCP through the means established between the two entities – can be by phone, secure email, or other.
Are Children's HCBS services placed on hold until all necessary approvals are received from the Medicaid Managed Care Plans (MMCPs)? What is the process to handle delays in MMCP approvals?
Services should not be delayed for child/youth in need of and eligible for HCBS. Providers are encouraged to request continued coverage of HCBS at least 14 days in advance of the current authorization’s expiration to avoid delays.
During the first 180 days HCBS services will be covered without MMCP utilization management (clinical review).
An enrollee has the right to request an appeal from the plan regarding a delay in approval, denial or reduction in services. With written consent, the provider may appeal on behalf of the enrollee. The enrollee also has fair hearing rights, once the plan’s appeal process is exhausted. The provider or the enrollee may also file a complaint at any time with the Department of Health at email@example.com
If the Children's HCBS provider has their own referral form can that be used instead of the State’s form?
No, the Referral for Home and Community Based Services (HCBS) to HCBS Provider form must be used. The form as a fillable PDF can be located here.