OUTSIDE REVIEW FAQ s

OUTSIDE REVIEW FAQ’s

A. University of New Mexico, Continuum of Care.

2. Q. What ISPs and budgets are required to be submitted to the OR for review from the case manager?

A. All adult DDW participants (18 and older) will transition to the OR process beginning with ISPs that expire in December 2015. All new adult allocations will use the OR process beginning November 1, 2015.

*Children and Jackson Class members will not use the OR.

3. Q. Will there be different timeframes for case managers (CM) completing and turning in ISPs? A. Yes. Case managers are required to submit the annual ISP, proposed budget and

supporting clinical documentation to the OR 60 days prior to the ISP expiration. 4. Q. Where do CMs submit ISPs and budgets for children and Jackson Class members?

A. Children and Jackson Class members will continue to submit ISPs and budgets to the Medicaid Third Party Assessor (TPA,) Qualis Health.

5. Q. If Qualis receives an ISP or budget that should have gone to the Outside Reviewer (OR) what happens?

A. Qualis Health will send the ISP and budget back to the CM via CISCO secure email indicating that it needs to go to the OR.

6. Q. What do CMs do with revisions?

A. Once an adult’s annual ISP and budget or initial ISP and budget (starting December 1, 2015 or after) is sent to the OR, all subsequent revisions go to the OR. CMs no longer submit anything to Qualis Health for ISPs and budgets. Current budgets that have not yet had an annual ISP and budget go to the OR. Any revisions prior to the next annual ISP will continue to go to Qualis Health until the next annual ISP term begins.

7. Q. If CMs have a revision that is simply changing providers does it go to the OR?

A. All revisions must go through the OR once the annual budget has been sent to the OR. 8. Q. What budget worksheet will be used to submit a budget to the OR?

A. DDSD will issue one (1) universal budget worksheet that will be used for all budget submissions to the OR. This budget worksheet will be distributed before October 1, 2015.

9. Q. What if CMs use the wrong DDW budget worksheet?

A. There will be one (1) universal budget worksheet used for everything that is sent to the OR. This budget worksheet will be distributed before October 1, 2015. If Qualis Health receives any revision or annual that is not on the current worksheet (version 2015 09 03) it will be RFId to the CM asking for a resubmission using the correct version. 10. Q. How will CMs submit ISPs and budgets to the OR?

A. ISPs and budgets will be sent using a secure email address via CISCO. Email address will be issued to case managers before October 1, 2015.

11. Q. Will CMs use CISCO as the secure way to submit ISPs, budgets and supporting clinical documentation to the OR?

OUTSIDE REVIEW FAQ’s

A. Yes-the OR will distribute naming conventions to be used.

13. Q. Once the OR approves or partially approves a budget, what happens?

A. Once the OR approves or partially approves a budget they send the approved budget to Qualis Health for data entry only. The OR approvals are binding on the State. Qualis Health will enter the budget into the Medicaid Management Information System

(Omnicaid) and issue a prior authorization to the case manager within 10 business days. The OR will send an approval letter to the case manager.

14. Q. If the OR only partially approves a budget, is there any course of action regarding the denied services prior to initiation of an Agency Review Conference or Fair Hearing?

A. No.

15. Q. What happens if the OR needs more information from the team to make a clinical determination?

A. An RFI may be sent to case managers, who will have ten business days to respond. If case managers do not respond in 10 business days, there will be a technical denial issued.

16. Q. If services are partially denied or denied in whole by the OR, will DDW recipients have a right to a Fair Hearing?

A. Yes. With every denial CM, individuals and guardian, if applicable, will receive a notice of rights to appeal.

17. Q. How will DDW participants be notified of their right to a Fair Hearing?

A. With every partial denial or denial in whole, a notice of right to appeal will be issued to the case manager, individual and guardian, if applicable.

18. Q. Will Qualis Health be sending approved prior authorizations to the case manager (CM)? A. Yes, also to the individual and their guardian, if applicable.

19. Q. Will the OR be sending approved prior authorizations to the CM? A. No, Qualis Health will be sending approved prior authorizations. 20. Q. Will CMs fax anything to the OR?

A. No, everything will be sent via secure email (CISCO). 21. Q. Will the OR RFI a budget that exceeds the Base Budget?

A. No, if clinical criteria are met and services and units are clinically justified by the OR, they will be approved.

22. Q. Will DDW recipients still get a DDW Group assignment?

A. Yes. DDW recipients will continue to receive DDW Group assignments. 23. Q. Will DDW recipients still get a Service Package and Base Budget amount?

A. DDW recipients will receive a proposed Service Package and a proposed Base Budget amount. Teams are encouraged to consider the DDW Group’s suggested Service Package and proposed budget but may request any DDW service and service amount that the team feels is clinically necessary to meet the person’s needs.

OUTSIDE REVIEW FAQ’s

25. Q. Can CMs hand deliver ISPs, budgets or clinical documentation to the OR? A. No.

26. Q. What is JIVA?

A. JIVA is Qualis Health’s internal secure electronic communication system. Only Qualis Health and the OR will have access to and use JIVA to communicate.

27. Q. If Qualis Health makes a data entry error who does the CM contact to get it fixed? A. Qualis Health-not the OR.

28. Q. Will CMs and teams get a checklist of what they need to submit for clinical justification and supporting documentation when requesting ISPs, services and service amounts?

A. No. CMs and teams need to refer to the DDSD Service/Clinical Criteria. Teams may submit any relevant information to justify requests. DDSD will be distributing a

crosswalk that outlines places within the ISP to document clinical justification of support needs.

29. Q. What is a Person-Centered Assessment?

A. A person centered assessment can include all assessments that employment and day programs currently use. Current examples include: VAP, MAP, PATH, and My Star or other agency-created assessment.

30. Q. Who is qualified to conduct person-centered assessments for employment and day services?

A. The provider agency is responsible to conduct person-centered assessments. The provider will be responsible for the quality of assessments.

31. Q. How are providers going to be reimbursed for the person-centered assessments for initial budgets or new allocations?

A. For initial budgets or new allocations, an assessment will not be in place. It is

recommended that the provider conduct an assessment on the individual who is new to them within the first 90 days of service delivery.

32. Q. Can providers be reimbursed for Meaningful Day activities?

A. Yes. Providers can be reimbursed for providing services related to the Meaningful Day (MD) definition. The provider must maintain the necessary billing documentation to support the delivery of the service. In addition, each paid service on the budget for day and employment services must be working towards a Vision-driven desired outcome in the ISP.

33. Q. Are there any Meaningful Day activities providers may not be reimbursed for? A. Yes. Activities that are part of daily, weekly, monthly (etc.) rituals that are very

meaningful to the person but are not related to a Vision-driven desired outcome, and/or activities related to skill maintenance and skill development may not be reimbursed. Examples: going to the movies on a weekly basis, eating at McDonald’s etc. (If any such activities are related to a specific Vision-driven outcome or skill building that is clearly justified,

OUTSIDE REVIEW FAQ’s

34. Q. If an individual is working on MD activity that is about skill maintenance related to a previously accomplished outcome, or another MD skill activity that is not related to a current Vision-driven outcome in their plan, but is about skill building, can providers also be

reimbursed for those Meaningful Day activities? A. Yes.

35. Q. How do teams develop a business plan for the self-employment requirement?

A. The local DVR is the best place to seek assistance in the development of a business plan. DDSD can also provide a template for business plans upon request through the regional DDSD community inclusion coordinator. The internet is also a source for business plan templates. In addition, DDSD works with the CDD through Partners for Employment to provide training opportunities: http://www.cdd.unm.edu/PFE/index.html. This website provides updated information about upcoming trainings. It also provides resources and tip sheets on various topics including microenterprises. Here is the link for

microenterprise tip sheet:

http://www.cdd.unm.edu/infonet/docs/newtipsheets/microenterprise%20tip%20sheet. pdf. If there is a training or resource that is not currently being offered and is needed, contact Carrie Roberts at DDSD to request a training. Email:

[email protected].

36. Q. Job Maintenance only allows 4 months of job development during an ISP year. How do providers request an exception to this?

A. The exception process will be developed. It will go through the Outside Reviewer. 37. Q. If an individual changes providers during job development, can the new provider be

approved for an additional 4 months of job development? A. Yes.

38. Q. Where do teams insert Service/Clinical Criteria into the ISP?

A. An ISP-Service/Clinical Criteria Crosswalk will be issued with suggestions for places to insert criteria; teams may insert criteria where they feel it is relevant at their discretion, however the ISP must remain a person-centered document and not a service-oriented document.

39. Q. Would it be appropriate to include Service/Clinical Criteria and/or support needs in Vision statements and desired outcomes?

A. No. Vision statements must be driven by the person and not services. 40. Q. Will there be a new ISP document?

A. Yes in the near future.

41. Q. How many reviewers will the OR have?

A. The OR will have 10-12 reviewers. This will be monitored by DDSD to ensure adequate capacity.

42. Q. How does the H Authorization process work in conjunction with the OR?

OUTSIDE REVIEW FAQ’s

43. Q. Will Qualis hold up a review of an annual ISP and budget if there is a problem with the category of eligibility or the LOC?

A. No. The OR will complete the clinical review and send the decision to Qualis. If Qualis receives a budget and there is a problem with eligibility, Qualis will send an RFI to the CM requesting what is needed to resolve the LOC or category of eligibility issue. 44. Q. Will the OR track late case management ISP and budget submissions?

A. Yes. The OR will track all late ISP and budget submissions and report this to DDSD monthly.