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Utilization Management

(Policies & Procedures Updated 6-12-18)

1 Role of the Utilization Management (UM) Department

Utilization Managers review beneficiary treatment plans and approve the specific number, type and duration of services or units delivered trying to ensure that services the beneficiary receive can provide the outcomes desired in the most independent and cost effective setting.  They seek to ensure that services are provided to those who are eligible and for whom the service is necessary.  As a result, they hope to ensure adequate resources are available for all who need assistance. 

2 Services Authorized by the UM Department

Specific details and criteria regarding the following Medicaid State Plan services may be found in the current Medicaid Provider Manual, Section 3 -- Covered Services.  Additional LifeWays processes are noted below.

ACUTE SERVICES (AVAILABLE VIA THE LIFEWAYS ACCESS DEPARTMENT)

  • Psychiatric Inpatient
  • Partial Hospitalization
  • Crisis Residential
  • Intensive Crisis Intervention
  • Crisis Interventions

APPLIED BEHAVIORAL ANALYSIS (ABA) - Available to children up to age 5 who are diagnosed with Autism.  The referral process for this benefit begins in the LifeWays Access department and has special process required.

ASSERTIVE COMMUNITY TREATMENT (ACT)

ASSESSMENTS - Includes Psychosocial Assessments, Psychological Testing, and Psychiatric Evaluations.

BEHAVIOR TREATMENT - Includes the development and monitoring of Behavior Treatment Plans for those with behavioral disturbances and as required by the mental health code.

CLUBHOUSE (PSYCHOSOCIAL REHABILITATION)

ECT (ELECTROCONVULSIVE THERAPY) - This procedure requires special review.  Requests should be sent by the ECT provider (hospital) directly to the UM supervisor.  (See ECT Procedure)

HEALTH SERVICES - Includes Occupational Therapy, Nursing, Nutritional Therapy, Physical Therapy, and Speech/Language Therapy.

HOME-BASED SERVICES - Intensive therapy services for children and their families delivered at home or in the community.  This includes Multi-Systemic Therapy which is limited to those with Medicaid coverages.

MEDICATION ADMINISTRATION AND REVIEW

NURSING FACILITY MENTAL HEALTH MONITORING

PERSONAL CARE (IN LICENSED SPECIALIZED RESIDENTIAL) - Primary Case Holder must compete the PC/CLS form during the PCP process.  The form is available in the Help menu of LEO and when completed is attached to the treatment plan.

TARGETED CASE MANAGEMENT

THERAPY

TRANSPORTATION - To CMH services when other transportation is not available or appropriate.  The DHHS and Medicaid Health Plans are responsible to provide transportation for their beneficiaries’ appointments.

TREATMENT PLANNING

WRAPAROUND - The following services are available to Medicaid beneficiaries unless they have a Medicaid waiver other than the Habitation Waiver.  Specific details and criteria are listed in the current version of the Medicaid Providers Manual, Section 17 – Additional Mental Health Services (B3).  Additional LifeWays processes are listed below:

ASSISTIVE TECHNOLOGY

COMMUNITY LIVING SUPPORTS (CLS) - See notes under Personal Care above.

ENHANCED PHARMACY

ENVIRONMENTAL MODIFICATIONS

FAMILY SUPPORT AND TRAINING

HOUSING ASSISTANCE

PEER SERVICES

RESPITE

SKILL-BUILDING

SUPPORT COORDINATION

SUPPORTED EMPLOYMENT

FISCAL INTERMEDIARY - Self-Determination arrangements have additional processes involved.  Please contact a UM staff member for additional information.

The following services are available to the uninsured based on their ability to pay:

  1. Brief Therapy via LifeWays Access
  2. Intensive Case Management from LifeWays following inpatient Admission
  3. Inpatient Admission
  4. Crisis Residential
  5. Intensive Crisis Stabilization
  6. Other services listed above if there is a high level of functional impairment on a case-by-case basis.

Additional Services to the above “State Plan” and “B3” services are available for those with Habilitation Services Waiver, Children’s Waiver, and SED Waiver and more information is available in the current Medicaid Provider Manual, Mental Health and Substance Abuse Section. 

3 Eligibility

Eligibility determination is the result of integrating eligibility criteria and clinical needs with current insurance benefits.  To be eligible for Community Mental Health (CMH)/ Prepaid Inpatient Health Plan (PIHP) services you must have the following:

One of the following conditions (as defined by the Michigan Mental Health Code):

"Developmental disability" means either of the following:

(a)  If applied to an individual older than 5 years of age, a severe, chronic condition that meets all of the following requirements:

(i) Is attributable to a mental or physical impairment or a combination of mental and physical impairments.

(ii) Is manifested before the individual is 22 years old.

(iii) Is likely to continue indefinitely.

(iv) Results in substantial functional limitations in 3 or more of the following areas of major life activity:

(A) Self-care.

(B) Receptive and expressive language.

(C) Learning.

(D) Mobility.

(E) Self-direction.

(F) Capacity for independent living.

(G) Economic self-sufficiency.

(v)   Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. (b) If applied to a minor from birth to 5 years of age, a substantial developmental delay or a specific congenital or acquired condition with a high probability of resulting in developmental disability as defined in subdivision (a) if services are not provided.

"Intellectual disability" means a condition manifesting before the age of 18 years that is characterized by significantly subaverage intellectual functioning and related limitations in 2 or more adaptive skills and that is diagnosed based on the following assumptions:

(a)  Valid assessment considers cultural and linguistic diversity, as well as differences in communication and behavioral factors.

(b)  The existence of limitation in adaptive skills occurs within the context of community environments typical of the individual's age peers and is indexed to the individual's particular needs for support.

(c)   Specific adaptive skill limitations often coexist with strengths in other adaptive skills or other personal capabilities.

(d)  With appropriate supports over a sustained period, the life functioning of the individual with an intellectual disability will generally improve

(e)  Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.

(b)  If applied to a minor from birth to 5 years of age, a substantial developmental delay or a specific congenital or acquired condition with a high probability of resulting in developmental disability as defined in subdivision (a) if services are not provided.

"Serious emotional disturbance" means a diagnosable mental, behavioral, or emotional disorder affecting a minor that exists or has existed during the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent diagnostic and statistical manual of mental disorders published by the American psychiatric association and approved by the department and that has resulted in functional impairment that substantially interferes with or limits the minor's role or functioning in family, school, or community activities. The following disorders are included only if they occur in conjunction with another diagnosable serious emotional disturbance:

(a)  A substance use disorder.

(b)  A developmental disorder.

(c)   "V" codes in the diagnostic and statistical manual of mental disorders.

"Serious mental illness" means a diagnosable mental, behavioral, or emotional disorder affecting an adult that exists or has existed within the past year for a period of time sufficient to meet diagnostic criteria specified in the most recent diagnostic and statistical manual of mental disorders published by the American psychiatric association and approved by the department and that has resulted in functional impairment that substantially interferes with or limits 1 or more major life activities. Serious mental illness includes dementia with delusions, dementia with depressed mood, and dementia with behavioral disturbance but does not include any other dementia unless the dementia occurs in conjunction with another diagnosable serious mental illness. The following disorders also are included only if they occur in conjunction with another diagnosable serious mental illness:

(a)  A substance use disorder.

(b)  A developmental disorder.

One of the following coverages for residents of Jackson or Hillsdale County:

Medicaid or Healthy Michigan:

                LifeWays provides services to those who have active Medicaid coverage or Healthy Michigan Plan coverage.  If the beneficiary has additional benefits (Medicare/ BCBS) those benefits would be applied first.  If the beneficiary has a Medicaid Health Plan, they would receive mental health services from a provider in the health plan’s network unless the need exceeds the health plan benefit. 

Habitation Supports Waiver

Serious Emotional Disturbance Waiver

Children’s Waiver

Beneficiaries who are the Responsibility of another County’s CMH/PIHP

           Those who are eligible for services in another county’s CMH may be approved to receive services within Jackson or Hillsdale County through a contract with their home county.  The most common example of this is someone who moved from independent living in their home county to a dependent living arrangement (AFC or Nursing Home) within Jackson/Hillsdale. 

General Fund services for the uninsured:

                To receive services an individual must complete a Medicaid application and participate in and ability to pay/financial evaluation to determine the maximum monthly amount of services they would be responsible according to State guidelines. 

4 Medical Necessity

A determination that a specific service is medically (clinically) appropriate, necessary to meet an individual’s needs, consistent with the person’s diagnosis, symptomology and functional impairments, is the most cost-effective option in the least restrictive environment, and is consistent with clinical standards of care. Additional information regarding Medical Necessity is located in the Medicaid Provider Manual, Mental Health and Substance Abuse, Section 2.5. 

5 Level of Functioning

As part of the initial and annual psychosocial assessment process, Level of Functioning scales are completed to provide data for determining the level of care need.  The following are required:

  • PECFAS or CAFAS for children.
  • LOCUS for adults with a Serious Mental Illness.
  • Supports Intensity Scale (SIS) for adults with an Intellectual or Developmental Disability.

6 Level of Care

The level of care determination is based on information gathered during the initial assessment, person-centered planning process and on clinical and demographic information documented in the medical record.

Clinicians will use established criteria to establish medical necessity and determine/identify level of service needs.  This may include:

  • Screening/LOC Tools
  • Functional Measures
  • Diagnosis – including presence of co-morbid conditions
  • Duration of the condition(s)
  • Symptoms
  • The impact of the condition on the individual’s ability to function
  • Support needs of the individual
  • Psychosocial factors
  • Risk factors

7 Service Authorization Process

Once the dimensions of an individual’s needs are assessed using a common framework, a focused treatment plan can be developed to address those identified needs.  Authorization requests for specific services, including the type of service, the amount and duration of the service, and the start date of the service are entered into LEO. 

Where/When to enter an authorization request in LEO:

  1. In the Treatment Plan document:  At the Person-Centered Planning meeting the team should determine which services to request and the amount, duration and start date of each for the upcoming year.
    1. Requests should be as specific as possible (2 units/month vs. 24 units per auth)
    2. Requests should not be automatically for 1 year, but the duration should be discussed in the meeting.
  2. Via a Treatment Plan Addendum document
    1. To request an increased frequency or to extend the duration the need should be reviewed and rationale given via the Treatment Plan addendum document.
    2. For significant changes in the treatment plan a formal review should be completed (change in primary service).
  3. Manual entry via a consumer’s authorization page for administrative reasons such as changing a code, transferring location/provider, or adding a service identified in the plan but mistakenly not requested.

Additional technical guidance related to entering authorization requests in LEO can be found in the help tab inside LEO.

8 Transition and Discharge of Cases

A transition summary is used to move from one level of care to another. A discharge summary is completed when consumer will be closed (planned/unplanned) from LifeWays. Please reference the below procedure 04-02.11 Transition/Discharge Planning.

9 Inpatient Treatment/ Alternative Treatment Orders

Primary Case Holders are required by the Mental Health Code to review/update Treatment plans when a consumer is admitted to the hospital to ensure that the plan remains appropriate.  The following procedure identifies the role of case holders when someone on their case load is admitted:

The Inpatient Services Manager of the UM team attends court hearings and serves as a liaison with the probate courts regarding treatment orders.  The following procedures identify provider and LifeWays staff roles in monitoring and reporting relative to these orders.

10 Case Consultation

Case consultation is available from LifeWays in the following venues, however, generally the treatment team makes the final decision regarding the plan. The treatment team should have specific questions and those questions should have been discussed within the primary provider’s clinical leadership/peer review structure. 

Diversion Meeting

Residential Meeting

11 Under and Over Utilization

Once a Treatment Plan is complete (all authorizations are completed by UM and the plan has been sent to the beneficiary/guardian) it is the expectation that the clinical record show one of the following:

  1.  The consumer received the services in the scope, amount, and frequency from the start date for the duration as approved.
  2. The reason each time a services has not been provided as approved (e.g. consumer was on vacation) and that consistent utilization issues be addressed and the plan changed if needed via the Treatment Plan Addendum and/or Formal Review. 

12 Utilization Review Committee

The Utilization Review Committee (URC) evaluates the utilization of services with the goal of ensuring that each consumer receives the right services, in the right amount, in the most appropriate time frames to achieve the best outcomes. The URC follows an annual plan that outlines the agency’s goals and key areas for ongoing performance monitoring.  The committee serves as a vehicle to communicate and coordinate quality improvement efforts to and with the Quality Improvement Council. 

13 Utilization Management Policies & Procedures

04-01 Service Authorization

      4-01.01 Authorization of LifeWays Network Services

      4-01.02 Clinical Competency     

04-02 Clinical Program Management

      4-02.01 Clinical Case Reviews

      4-02.02 Habilitation and Supports Waiver – C Waiver

      4-02.03 Projects for Assistance in Transition from Homelessness – PATH

      4-02.04 Self Determination Practice Guidelines

      4-02.05 OBRA Coordination

      4-02.06 Wraparound Implementation

      4-02.07 Children’s Waiver Service

      4-02.08 Alternative Treatment Order Monitoring

      4-02.09 Respite

      4-02.10 Recovery-Based Services

      4-02.11 Transition/Discharge Planning

      4-02.12 SEDW Services

      4-02.13 Residential Services

      4-02.14 Monitoring and Reassessment

      4-02.15 Behavioral Health Treatment Services for Children with Autism Spectrum Disorders

      4-02.16 Inpatient Hospital Coordination of Care

      4-02.17 Supports Intensity Scale (SIS)

      4-02.18 Involuntary Commitment – Court Proceeding

      4-02.19 Involuntary Admission – Deferral of Hearing

      4-02.20 Voluntary vs. Involuntary Inpatient Admissions of Adults

      4-02.21 Housing Assistance

      4-02.22 Person-Centered Planning

      4-02.23 Enhanced Health Services Prescription Requirement

      4-02.24 Mental Health Court Jail Diversion

      4-02.25 Multisystemic Therapy (MST)

      4-02.26 Zero to Three (0-3) Infant Mental Health

      4-02.27 Supported Employment

04-03 Utilization

      4-03.01 Utilization Management Criteria

      4-03.02 Utilization Review Committee

      4-03.03 Medicaid Fair Hearing Procedure

      4-03.04 Diversion Meeting

      4-03.05 Utilization Review

14 Service Descriptions

MEDICAID SERVICES AND SUPPORTS

A description of all services can be found in the Medicaid Provider Manual under the following sections of Mental Health/Substance Abuse:

Section 3: Covered Services

Section 4: Assertive Community Treatment Program

Section 5: Clubhouse Psychosocial Rehabilitation Programs

Section 6: Crisis Residential Services

Section 7: Home-Based Services

Section 8: Inpatient Psychiatric Hospital

Section 9: Intensive Crisis Stabilization

Section 10: Outpatient Partial Hospitalization

Section 11: Personal Care in Licensed Specialized Residential Settings

Section 12: Substance Abuse

Section 13: Targeted Case Management

Section 14: Children’s Home and Community Based Services Waiver (CWP)

Section 15: Habilitation Supports Waiver for Persons with Developmental Disabilities (HSW)

Section 16: Mental Health & School Based Services

Section 17: Additional Mental Health Services (B3s)

Section 18: Applied Behavior Analysis

Link: Michigan Medicaid Manual