Western Highlands Provider Friday Newsletter, 9/07/07

	Western Highlands Network
	Friday E-Mail Newsletter Number 99 9/07/2007 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. Life Beyond 7/15/07 With the changes made by the Division of Mental Health and the Division of Medical Assistance, Western Highlands has worked to make access to care as simple as possible. For more information on the Accessing Care Training, see the Division of Mental Health website at http://www.dhhs.state.nc.us/mhddsas/training/access-care/index.htm for a complete set of documents from this series of statewide trainings. This newsletter can be used as a reference for understanding how requests for services enter Western Highlands, how they are processed and reviewed, and how they result in authorization for medically necessary services. For New Consumers, the Process Starts with Access For the consumer who has never had services before, requests for State Funds enter Western Highlands in two ways. The consumer enters the office of a provider requesting services (No Wrong Door). The consumer calls Access seeking care. In either case, consumers are evaluated for care. If they have Medicaid, this entitles the consumer to an array of clinically necessary services. If they meet a Target Population for state funded services (IPRS only), they are not entitled to, but may have access to a more modest array of services. Generally, after screening, the process for accessing state funds follows: Comprehensive Clinical Assessments (only one assessment is allowed) on new consumers will be authorized retroactively up to 5 days after the event. The CCA includes many types of assessments, including the Diagnostic Assessment. It is the provider’s responsibility to perform the appropriate assessment for the consumer’s presenting problem. When all of the necessary paperwork is completed (STR, PCP Consumer Admission Form, IPRS assignment, Introductory or Complete PCP, Consumer Consent and Description of Clinical Issues), the Qualified Professional from one of the nine clinical homes (ACTT, CS Adult, CS Child, Community Support Team, SAIOP, SACOT, Intensive In Home Service, MST, and Targeted Case Management) can request up to a 30 day authorization for the services of the designated clinical home. Shortly before this initial 30 day authorization expires, QPs will submit to Western Highlands a SAR to Services Management for longer term services and a supporting Complete PCP. Service Authorization Requests which fall into “standard care” will be reviewed by Authorization Technicians, and most of these (around 75% of all requests processed by Western Highlands) are approved and authorized. The timeline for this process is currently 2 days when there are no complications. Some requests are reviewed by Clinical Specialists. This occurs randomly in some cases, and always occurs if the justification for the service is not clear or exceeds “standard care guidelines”. You may notice that this level of review is scrutinized more thoroughly than the more quantitative review performed by Authorization Technicians. Turn around on these cases is currently 2 days, but often involves consultation with the provider by Clinical Specialists, but generally are resolved in less than a week from receipt of the SAR. General Notes to consider... If someone revises a PCP (including reviewing and continuing goals as “Ongoing”) Western Highlands is PENDING for the new Complete PCP format. Your Complete PCP and signatures are valid for up to a year UNLESS you have Added a service Changed the diagnosis Performed an annual review Changed provider Revisions to the PCP include: Reviewing a goal filling out the status and updating a target date Adding/discontinuing goals Changing/adding a service Changing/adding a diagnosis Please note that if a SAR is rejected or denied due to the pend limit expiring, you must start over with the request process. Electronic Entry of SARs is Coming! In the near future, providers will be offered access to direct entry of information in the Western Highlands system. Please make sure you have submitted to us the Consumer Consent Form. This will allow you access to the consumer’s electronic record. This will assist in minimizing SAR errors. This function will also allow you to check the status of authorizations. More information soon! New UR Guidelines Coming for State Funds! Many of you are by now familiar with the new UR guidelines disseminated in the Access to Care Training performed recently by the state. Western Highlands will soon be posting an update of the Standard Care Grids. Please note that we will authorize “up to” the maximum time span, but may not in every case. Please read your LON carefully so you know the period of the authorization. PLEASE NOTE - All future calls to WHN by Providers should be to 1-800-671-6560. Please do not use 225-2800 as this is no longer the # for providers. If you are a provider calling Western Highlands from Buncombe County, use the local phone number 225-2785. You will find the most current SAR on the WHN website, and after 10/15/07 only the most current form will be accepted for processing. PLEASE MAKE A NOTE OF THIS! In order to respond to the many questions these changes have elicited, please send questions via the WHN website, under “Provider Questions”. We will try to consolidate questions and get you clear responses when we publish the Friday Email. Western Highlands Network 356 Biltmore Avenue Asheville, NC 28801 Phone: (828)225-2800 Fax: (828) 225-2779 E-Mail: ring@westernhighlands.org Website: www.westernhighlands.org