Western Highlands Network

Friday E-Mail Newsletter

Number 96
5/18/2007

The Friday E-Mail is a weekly update for providers by the Services Management Department of Western Highlands Network. Please distribute to all your staff.

CASES MUST BE OPENED BEFORE COMMUNITY SUPPORT BEGINS!

We have encountered several problems recently which indicate that providers are using the Community Support (CS) authorized by Access before cases are opened. Also, some providers are billing Community Support activities under the Assertive Outreach target population. There are several billing and treatment problems arising from these practices.
First, the Assertive Outreach Target Population only covers one billable event. Second, the Assertive Outreach definition specifies that this Target Population is only to be assigned to those consumers who do not qualify for any other target population. This is the mechanism for providers to be reimbursed for assessments when the consumer does not meet other Target Population criteria. Lastly, careful reading of the Assertive Outreach Target Population definition reveals that it is only available if the consumer has been “referred by the LME” and is therefore not usable for “no wrong door” assessments. CS interventions billed under the Assertive Outreach Target Population cannot be reimbursed.

Initiating interventions without a thorough assessment puts consumers at risk for harm and providers at risk for malpractice. Best practice is to clinically evaluate the consumer face to face at the first contact, and open the case. The evaluation and any subsequent CS should be billed under the Target Population for which the consumer meets criteria. Please note that while a full Diagnostic Assessment must be completed for many consumers, a completed DA is not a requirement for case opening.

Your admit date must be the date of the first face to face contact. This helps protect both the consumer and the provider. This issue has been subject to scrutiny in recent CS audits, and has resulted in significant paybacks. It was also a topic of concern at the recent FARO conference.

What follows is a list of common case opening scenarios. Please send the documents appropriate to each situation so you can properly register your consumer and/or open the case:

1. Medicaid Consumer - Registration Only - Entering the system through WH Access telephone screening

WH Access completes the screening and sends it to the provider chosen by the consumer. The provider must fax the following forms to WH Access at (828) 225-2782 within 5 working days of initial contact with the consumer.

  • STR Form – “Registration Only” sections (A-J, 1, and 49-55)

2. Medicaid Consumer - “No Wrong Door” - STR completed by the provider

The provider must fax the following forms to WH Access at (828) 225-2782 within 5 working days of initial contact with the consumer. Failure to register a Medicaid consumer may jeopardize reimbursement.

  • STR Form and registration completed in full
  • “Description of Consumer Clinical Issues” form (complete sections A and B)
  • WHN Consumer Consent Form

3. Medicaid Consumer - “No Wrong Door” - STR completed by provider with request for H Code authorization (Provisionally Licensed Therapist)

To register a Medicaid consumer and seek authorization for services billed through the LME, the following forms must be faxed to Access at (828) 225-2782 within 5 working days.

  • STR Form and registration completed in full
  • “Description of Consumer Clinical Issues” form (complete A,B and C)
  • PCP Consumer Admission Form
  • WHN Consumer Consent Form
  • IPRS Worksheet (if requesting State Funds)

4. State Funded (IPRS) Consumers – No Wrong Door-STR completed by the provider

To open the consumer’s case in the WH system and request authorizations for State funded services the provider must fax the following forms to Access at (828) 225-2782 within 5 working days of initial contact.

  • STR Form and registration completed in full
  • “Description of Consumer Clinical Issues” form (complete sections A, B and C)
  • IPRS Worksheet (only required for case opening)
  • PCP Consumer Admission Form
  • WHN Consumer Consent Form

5. State Funded (IPRS) Consumers –No Wrong Door- Face to face assessment for consumers who do not meet any Target Pop criteria
There is no reimbursement for this service. Assessments for state funded (IPRS) consumers is only reimbursable if the consumer is referred to the provider by WH Access (as noted in the first paragraph above)

6. State Funded (IPRS) Consumer - STR completed by WH Access (fax to 828-225-2782)

  • WH Access will send screening and initial authorization to provider
  • Provider sends PCP Admission Form
  • IPRS Worksheet
  • WHN Consumer Consent Form
  • Provider requests further authorizations via WH Service Management

7. State Funded (IPRS) Consumer - STR completed by WH Access and the provider’s assessment determines the consumer does not meet Target pop. criteria (fax to WH Access at 828-225-2782)

  • Return only the “Description of Consumer Clinical Issues” form (complete sections A, B, and C)
  • This assessment is the one event that can be billed/reimbursed under the Assertive Outreach Target Population (as noted in the first paragraph above)

WHN will pend incomplete forms and administratively deny if not corrected within 14 days.

 

Charlie Schoenheit
Director of Services Management
Western Highlands Network
356 Biltmore Avenue
Asheville, NC 28801
Telephone: (828)258-3511 x2219
FAX: (828) 225-2779
E-Mail: Charlie@westernhighlands.org
Website: westernhighlands.org