Georgia

Outpatient

Treatment

Requests

Objectives

As a result of this training, participants will be knowledgeable of:

• How to successfully complete GA OTRs

• Frequently requested GA codes

• Tips that are useful when submitting OTRs

• Common Errors to avoid with GA OTRs

OUTPATIENT TREATMENT REQUEST FORM

• Member Information

• DSM-IV Diagnosis

• Functional Outcomes

• Therapeutic Approach

• Level of Improvement

• Symptoms

• Functional Impairment

• Risk Assessment

OUTPATIENT TREATMENT REQUEST FORM

• Treatment Goals

• Requested Authorization

• Additional Information

• Name/Signature/Date

Ensure letters and fonts are legible

Complete with full name of member

Member ID number is a 12 digit member number

Enter complete provider’s name, tax id and NPI number

Complete facility phone number

Complete facility fax number to send notification to coverage

MEMBER/PROVIDER INFORMATION

DSM – IV TR DIAGNOSIS

Complete Axes I – V using the DSM IV - TR multi-axial format

DSM code and DSM description entered should match

Answer if provider has contact with the PCP, check yes/no

On each OTR, enter the first and last date seen by provider

FUNCTIONAL OUTCOMES

Complete during assessment with the member or guardian

Answers should change based on current functioning

Section should be updated on each OTR

Note: Questions 9 & 10 are for children, 11 & 12 are for adults

THERAPEUTIC APPROACH/

LEVELS OF IMPROVEMENT

Indicate Therapeutic Approach/Evidence Based Treatment used

(i.e., DBT, CBT, Reality Therapy, Play Therapy)

Level of Improvement should be updated on each OTR request

If Minor/No progress, indicate what treatment changes will be made

Indicate what is current or possible hindrances to discharge

SYMPTOMS

Check only present symptoms – within last 30 days

Indicate to what degree symptoms impact daily functioning

Check list should be updated on each OTR request

OOH Placement (if present) may be marked in space ‘other’

One box should be checked for each line, check N/A if not present

FUNCTIONAL IMPAIRMENTS

• Indicate to what degree symptoms impact daily functioning

• Check list should be updated on each OTR request

• If substance use, indicate drug of choice and date of last use

• Impairments should be addressed on OTR or treatment plan

RISK ASSESSMENT

Indicate suicidal and homicidal risks – current and historical

• Current – Ideation (thoughts, plan, imminent intent )within last 30 days

• History – Past self harming behaviors or harm to others

If risk factor is noted, please indicate if safety plan is in place

Check if member is compliant with psychotropic medication

TREATMENT GOALS

Goals should be updated and changed over time

Progress should indicate how treatment is beneficial

Should address symptoms and/or functional impairments

Use SMART technique when stating goals

Each requested service needs to have a corresponding treatment

goal

Measurable Goals/Objectives/Interventions

Objective Goals are SMART, not Vague

SPECIFIC – Who, What, When, Where, and How

MEASURABLE – Intensity, Frequency, Duration of Symptoms

Use a quantitative format – (i.e., 6X, 80%)

ATTAINABLE – Within the member’s scope or capability for the

current treatment episode?

REALISTIC – Is the bar set too high or too low for this member?

TIME-LIMITED – Is it an opportune time for the member to pursue the

identified goals? Use specific timeframes

Client will decrease anger outbursts from 15x a week to 7x a week by

using learned anger management skills, over the next 90 days

SMART GOALS

REQUESTED AUTHORIZATION

Complete for currently needed pre-authorized services only

Start Date: Date each service is started, dates may be different

Frequency: How often will client be seen? (i.e., 2x/month)

Intensity: Length of time per visit, # of units (1 unit=15 mins)

Requested start date of authorization

Anticipated completion date

Start dates can only be backdated 1 day before received date

Note modifiers for some codes

ADDITIONAL INFORMATION

Use to request H2017, if an authorized provider

Add any relevant information which supports the need for requested

services – symptoms, level of functioning, etc.

What traditional behavioral health services been attempted?

Address lack of progress by adding new interventions or new goals

It is mandatory to enter the provider’s name, signature and date

Commonly Requested Codes

• 9 Codes - Behavioral Health Outpatient Services(BHOP)

• H0004 - Group/Family Psychotherapy

• H0036 - Intensive Family Intervention

• H0039 - Assertive Community Therapy

• H2011 - Crisis Intervention Services

• H2014 - Group/Family Skills Training

• H2015 - Community Support Individuals

• H2015 HF - Addictive Disease Support

• T1016 - Targeted Case Management

• H2017 - Psychosocial Rehabilitation

Behavioral Health Outpatient Services

BHOP - 9 codes/billed as CPT codes

Description:

Individual/Group/Family Psychotherapy. Effective 8/24/2014

pre-authorization needed for clinicians who are NOT fully licensed

• Lowest Level of Care

• 9 codes units are bundled together in Cenpatico’s system

• Individual Therapy (IT) - CPT code 90837

• Family Therapy (FT) - CPT code 90847

• Group Therapy (GT) - CPT code 90853

Medical Necessity Criteria (MNC):

MNC is determined by Interqual or ASAM

Community Based Service Codes

H0004 – Behavioral Health Counseling and Therapy

(Family/Group)

Description: Family Psychotherapy involves interaction between the member, staff and

the member’s family unit. Group Psychotherapy involves services to address

specific goals/skills, concerns or issues.

• Historically used for in-home family therapy and/or by non-licensed

master level clinicians

• Presently, can be interchanged with 90847 (family therapy) and 90853

(group therapy)

Medical Necessity Criteria (MNC):

MNC is determined by Interqual or ASAM

Community Based Service Codes H0036 - Intensive Family Intervention - Youth Only

Description:

Intensive Family Intervention (IFI) Services – Intense short term services designed

to improve family functioning, stabilize living arrangement, promote reunification,

and/or prevent out-of-home placement.

Medical Necessity Criteria (MNC): A & B and either C, D, E

A. Diagnosis/duration of symptoms which classify the illness as SED and/or is

diagnosed Substance Related Disorder.

B. Risk of OOHP or in an OOHP where reunification is imminent.

C. Member and/or family lack the skills to cope with an immediate behavioral

health crisis.

D. Member and/or family behavioral health issues are unmanageable in

traditional outpatient treatment.

E. Treatment at a lower intensity has been attempted or given serious

consideration.

Community Based Service Codes H0039 - Assertive Community Treatment (ACT)

Description:

Assertive Community Treatment– A recovery-focused, high intensity service for

members discharged from multiple or extended stays in psychiatric hospitals or

who are difficult to engage in treatment. Services are available 24 hours/7 days

a week. Goals must be clearly described by the provider.

Medical Necessity Criteria (MNC): A, B & C

A. Diagnosis of a severe and persistent mental illness that seriously impairs the

ability to live in the community.

B. Significant functional impairment as demonstrated by the inability to

consistently care for self (i.e., hygiene, nutrition, housing, employment)

C. The member has continuous high-service needs that are greater than 8 hours

per month (i.e., hospitalization, recurrent severe symptoms, co-existing

disorders). Lower level of service has been tried and found inappropriate or

ineffective.

Community Based Service Codes

H2011 - Crisis Intervention Services

Description:

Crisis Intervention is a time limited service designed to prevent out of home

placement or hospitalization. It could be used to manage or de-escalate a

crisis. This code cannot be processed ‘pre-crisis’ or ‘as needed’. OTR should

be submitted within 30 days of the crisis.

Medical Necessity Criteria (MNC):

A. Member has a known or suspected mental health diagnosis or

substance related disorder.

B. Member must be in active crisis - SI/HI or severe aggressive behaviors;

where there is a risk of harm to self, others and/or property.

C. Provider must note on the OTR how the crisis was handled and what was

the outcome (1013, developed a crisis plan, etc.)

Community Based Service Codes H2014 - Family Training/Group Skills Training

Description:

In a group format, teach parenting skills and family skills training with specific

activities to enhance the member’s recovery (i.e., anger management,

substance abuse prevention, social skills)

Medical Necessity Criteria (MNC):

A. Member must have a mental illness and/or substance-related disorder diagnosis that is destabilizing (markedly interferes with the ability to carry out activities of daily living or places others in danger) or distressing (causes mental anguish or suffering).

B. The plan of care must include treatment goals that clearly indicate how the service will be utilized. Goals must be specific, measurable, attainable, realistic, and time limited.

C. When clinical/functional needs are great, there must be complementary therapeutic services.

Community Based Service Codes

H2015 - Community Support Individuals

Description:

Teach member skills to improve functioning in the community, home and

school. Code can be used for parenting skills using the UK modifier.

Medical Necessity Criteria (MNC):

A. Children/Adolescents only.

B. DSM-IV Axis I-V diagnosis and must be assigned by a licensed psychologist,

physician, or a PA or APRN working in conjunction with a physician with an approved job description or protocol or LCSW.

C. There must be complementary therapeutic services. It is not intended to be used as a stand alone service.

D. The plan of care must include treatment goals that clearly indicate how the service

will be utilized. Goals must be specific, measurable, attainable, realistic, and time limited.

Community Based Service Codes H2015 HF Addictive Diseases Support Services

Description:

Specific to adults with addictive disease issues, focuses on substance abuse recovery services/supports and skill building

Medical Necessity Criteria (MNC):

A. Individuals with one of the following: Substance-Related Disorder, Co-Occurring

Substance-Related Disorder and MH Diagnosis, or Co-Occurring Substance-

Related Disorder and DD and

B. Must be willing to enroll in a program targeted to reduce and/or stop the use of harmful substances; and one or both of the following:

• Individual may need assistance with developing, maintaining, or enhancing social supports

or other community coping skills; or

• Individual may need assistance with daily living skills including coordination to

access necessary rehabilitative/medical services , employment, education, etc.

Community Based Service Codes

T1016 Case Management

Description:

Targets adults with severe psychiatric disabilities and assist individuals w/housing,

developing self-management skills, increase social/leisure skills

Medical Necessity Criteria (MNC):

• Priority given to those individuals with a psychotic disorder (e.g.,

schizoaffective disorder) or bipolar disorder; and one or more of the following:

A. Admission to a psychiatric inpatient setting or crisis stabilization unit

(i.e. within past 2 years);

B. Released from jail or prison (i.e. within past 2 years);

C. At-risk of OOHP or history of homelessness w/in the past 2 years

Community Based Service Codes

H2017 - Psychosocial Rehabilitation: Individual or Group

Description:

A therapeutic, rehabilitative, skill building and recovery promoting service intended to assist individuals in gaining the skills such social, vocational, and etcetera necessary to allow them to remain in or return to community settings and activities (Contracted

Providers Only)

Medical Necessity Criteria (MNC): Admission criteria A-D must be met

A. Individual must have primary behavioral health issues (including a co-occurring substance abuse disorder or MR/DD) and/or no risk of danger to themselves or others. The current symptoms and impairments indicate a LOCUS score of level 3 or higher.

B. Individual lacks many functional and essential life skills such as living, social skills, vocational/academic skills and/or community/family integration; or

C. Individual needs frequent assistance to obtain and use community resources.

D. A treatment plan that includes treatment goals that clearly indicate how the service will be utilized.

3 C’s of Clinical InformationAuthorization units are based on

clear, complete and consistent clinical information

• Severity/intensity of symptoms and functional impairments noted

• SMART goals/objectives for each service code requested

• Less services requested as member improves (titration)

• On average 3 – 6 months is considered adequate to teach skills

for community based codes (H-codes)

• Codes requested are congruent with symptoms severity/intensity

• Narrative and treatment plan supports severity/intensity of symptoms

• Updated attachments – dated within 6 months for treatment plan

• Lack of progress addressed

• H-Codes: H2014 - note whether for family or group

H2017 – note if a contracted provider

H0036/T1016 – note OOHP risk & specific/potential threat

TIPS - FAQWhat are the timelines for sending OTRs?

OTRs can be sent in up to 3 weeks in advance, however, OTRs cannot

be backdated more than 1 business day

When should I expect to get a response?Providers will receive a response 7 – 14 days of submission

Where do I send OTRs and attachments?Completed OTRs and attachments are faxed to 866 694-3649

What demographic information is essential?Complete All requested demographic information for member & provider

What happens if OTR is incomplete?Submitting an incomplete OTR may result in:

OTR being returned to you

Reduced authorization of units

Denial

What happens if OTR is denied?

Provider will receive a denial letter detailing appeal options

• The most up-to-date OTR form is on our website at www.cenpatico.com

• Update all OTRs. Avoid cutting & pasting previously submitted information

• An OTR with only requested dates changed may result in a denial

• Use S.M.A.R.T. goals/objectives

• Narratives and treatment plan should address diagnosis/symptoms

• Attachments should be current, completed within 1 month for clinical

information and 6 months for treatment plan

• It is mandatory to sign and date OTRs

Summaryvague, incomplete, inconsistent, non-clinically supported/explained OTRs

EQUAL

delayed, problem letter, less units, denial

REMINDERS

PROBLEM LETTER

SAMPLE OTR (incorrect)

SAMPLE OTR (correct)

Cenpatico Website: www.cenpatico.com

Cenpatico Phone Numbers: 1-800-947-0633

Health Plan Phone Number: 1-866-847-0633

Claims Phone Number: 1-866-324-3632

Claims Address: PO Box 6400, Farmington, MO 63640

IMPORTANT CONTACT INFORMATION

QUESTIONS