Psychiatric Rehabilitation Treatment Facility Diversion and Assessment Program Clinical Coverage Policy 8D-1 State Funded MH/SA/DD Service Definitions Service Code 0911 (modifier pending); up to 30 day assessment Pre-Review Review for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and Met Not N/A outreach phone call to Provider. Met Please note concerns here and in the Clinical Justification: Review for expedited criteria. If not met, notify provider and take off of expedited status. Met Not N/A Met Review for Unable to Process Criteria The requested effective start date does not precede the submission date of request. If Met Not Met unjustified retro request, then “unable to process”. The dates of the request do not overlap with an existing authorization for the same service. If not met, make documented contact with provider to verify intended request dates. Can Met Not Met adjust authorized dates as requested by provider. Please note here: The number of units requested match the date range requested: (One unit per day) If not met, make documented contact with provider to verify intended request units/dates. Can Met Not Met adjust authorized dates as requested by provider. Please note here: The SAR is submitted no more than 30 days before requested start date. If not met, then unable to process. Met Not Met Review for Administrative Denial: PCP is present, which includes the PRTF Diversion and Assessment Program, frequency and provider. If none present, then contact the provider to request and give deadline to submit. Met Not Met If no response, “administratively deny” the request. Initial PCP and/or Annual PCP Rewrite have signed service order and written date by Approved Signatory. In addition, the following are also present: Beneficiary and/or Legally Responsible Person signature Person Responsible for PCP signature DJJ and/or CFT attestation, if applicable Met Not Met Attestation boxes checked by Approved Signatory—if not checked, Administratively Deny For all others, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Review for Comprehensive Crisis Plan. If none present, then contact provider and give a Met Not Met deadline to submit. If no response, “administratively deny” the request.
Psychiatric Rehabilitation Treatment Facility Diversion and Assessment Program Clinical Coverage Policy 8D-1 State Funded MH/SA/DD Service Definitions Service Code 0911 (modifier pending); up to 30 day assessment Pre-Review Met Not Met N/A Review for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and outreach phone call to Provider. Please note concerns here and in the Clinical Justification: Met Not Met N/A Review for expedited criteria. If not met, notify provider and take off of expedited status. Review for Unable to Process Criteria Met Not Met The requested effective start date does not precede the submission date of request. If unjustified retro request, then “unable to process”. Met Not Met The dates of the request do not overlap with an existing authorization for the same service. If not met, make documented contact with provider to verify intended request dates. Can adjust authorized dates as requested by provider. Please note here: Met Not Met The number of units requested match the date range requested: (One unit per day) If not met, make documented contact with provider to verify intended request units/dates. Can adjust authorized dates as requested by provider. Please note here: Met Not Met The SAR is submitted no more than 30 days before requested start date. If not met, then unable to process. Review for Administrative Denial: Met Not Met PCP is present, which includes the PRTF Diversion and Assessment Program, frequency and provider. If none present, then contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Met Not Met Initial PCP and/or Annual PCP Rewrite have signed service order and written date by Approved Signatory. In addition, the following are also present: Beneficiary and/or Legally Responsible Person signature Person Responsible for PCP signature DJJ and/or CFT attestation, if applicable Attestation boxes checked by Approved Signatory—if not checked, Administratively Deny For all others, contact the provider to request and give deadline to submit. If no response, “administratively deny” the request. Met Not Met Review for Comprehensive Crisis Plan. If none present, then contact provider and give a deadline to submit. If no response, “administratively deny” the request.
PRTF-DAP-Service-Reveiw-Criteria08062015.docx