Current through Register Vol. 49, No. 9, September, 2024
Section
IIChild Health Management Services
203.100
Required CHMS Medical/Clinical
Records
CHMS providers are required to maintain the following
medical/clinical records.
A. A daily
log of patient visits shall be maintained by the CHMS clinic. The clinic staff
will record the entry and exit time of day of each client.
B. All CHMS services provided must be
recorded in the patient's record, dated and signed by the person performing the
service. The beginning and ending time of day of each service must be
recorded.
C. For CHMS
Diagnosis/Evaluation Services:
Complete and accurate clinical records must be maintained for
any patient who receives direct services from the CHMS clinic. Each record must
contain, at a minimum, the following information:
1. Identifying data and demographic
information;
2. Consent for service
and release of information forms required by law or local policy;
3. Referral source(s) as documented by a PCP
referral;
4. Reason(s) for referral
as documented on the PCP referral;
5. Content and results of all diagnostic
work-ups and/or problem assessments, including the source documents, e.g.,
social history, test protocols, mental status examination, history of
complaints, etc.;
6. Treatment plan
signed by a CHMS clinic physician;
7. Medication record of all prescribed and/or
administered medications;
8.
Progress notes and/or other documentation of:
a. Treatment received;
b. Referral for treatment;
c. Changes in the patient's situation or
condition;
d. Significant events in
the patient's life relevant to treatment and e. Response to
treatment.
9. Submittal
of prior authorization request (including intervention/treatment needed) to
CHMS prior authorization contractor when appropriate.
D. For CHMS Intervention/Treatment Services:
The following additional records must be maintained for
patients receiving treatment in pediatric day programs.
1. Documentation of completion of intake
process.
2. Documentation of
interdisciplinary evaluation to address presenting diagnosis and establish base
line of functioning and subsequent submission of prior authorization
request.
3. CHMS physician's
enrollment orders, form DMS-201, signed treatment plan and 6 month records
review completed and signed by a CHMS physician.
4. PCP initial referral and 6 month pediatric
day treatment referral.
5. Daily or
weekly treatment records documenting services provided, relation of service to
treatment plan and level of completion of treatment goal. Services must be
provided in accordance with the treatment plan, with clear documentation of the
services rendered.
a. If a child does not
receive all services as outlined in the treatment plan, there must be clear
documentation regarding the reason the prescribed services were not provided
(e.g. child absent, therapist unavailable, etc.)
b. If a child does not receive the prescribed
amount of therapy due to the unavailability of CHMS therapy staff for a period
of more than 2 (two) weeks, the primary care physician and the child's
parent/guardian must be notified of the missed therapy and given an estimated
time frame in which therapy services should resume at the prescribed
rate.
6. Revisions of
treatment plan including treatment goals will be documented at a minimum of
each six months, or more often if warranted by the patient's progress or lack
of progress.
218.400
Transition/Follow-Up
When it is determined that the patient no longer has a medical
need for therapy services, the treatment plan will be updated accordingly and
services will be discontinued. Releases to provide copies of testing results
and treatment records will be obtained, if appropriate. Follow-up with the
parent/patient will be made no more than 180 days following discontinuation of
therapy to determine the status of the patient. Follow-up may be as soon and as
frequent as the CHMS physician determines is necessary.
When it is determined that the patient no longer has a medical
need for intervention/treatment services, a transition conference will be held
with the relevant CHMS providers and the patient/parents. Releases to provide
copies of testing results and treatment records will be obtained, if
appropriate. Follow-up with the parent will be made no more than 180 days
following transition to determine the status of the patient. Follow-up may be
as soon and as frequent as the CHMS physician determines is necessary.
When CHMS multidisciplinary treatment services are no longer
medically necessary, or if CHMS services are discontinued for other reasons
(e.g. child is moving, parental/guardian request, etc.), the CHMS Discharge
Notification (DMS-202) must be completed and a copy submitted to AFMC within 30
(thirty) days of service termination.
222.000
Inspection of Care
Inspection of care will be performed in conjunction with the
certification site visits. A team of healthcare professionals will assess the
care needed by and provided to a sampling of CHMS patients.
For each inspection of care visit, AFMC will select patients
currently being served by the CHMS clinic. The AFMC team will review medical
records, and may interview patients, parents and staff and observe treatment in
progress.
A. The medical record review
will include assessment of the patient's continued medical necessity for Child
Health Management Services (CHMS), determining if the treatment plan is being
followed and if the therapy services are being provided as prescribed by the
primary care physician (subject to applicable authorizations and utilization
controls.
B. An AFMC team member
(determined by the patient's diagnosis and treatment program) may interview
staff and, if available, parents to assess the patient's needs, goals and
progress with treatment. The same team member may also meet, assess and observe
the patient in treatment.
C. In
addition to focusing on selected patients, the AFMC team will observe the
activities at the CHMS clinic for therapeutic function.
Any child determined to not meet the requirements for
enrollment in a CHMS clinic will be decertified from the program. A written
notification will be given to the clinic with a copy mailed to the parents of
the patient. The clinic/parents will be allowed thirty (30) calendar days to
request reconsideration of the patient decertification to AFMC. A
reconsideration of the decertification will be completed with notification to
the clinic and parents within fifteen (15) working days from receipt of the
appeal.
A written report of the inspection of care finding will be
mailed to the Division of Medical Services.
242.000
Prior Authorization Request to
Determine and Verify the Patient's
Need for Child Health Management Services
Intervention and treatment services for Medicaid beneficiaries
must be prior authorized in accordance with the following procedures.
A. When a recommendation is made for
intervention/treatment services, the CHMS Request for Prior Authorization form
DMS-102 must be completed by the CHMS clinic and submitted via mail or fax to
the Arkansas Foundation for Medical Care (AFMC). Fax transmission will be
limited to 25 pages. For those clinics wishing to utilize electronic
submission, contact AFMC and request specifics.
View or print
CHMS Request for Prior Authorization form DMS-102 and instructions for
completion. View or print AFMC contact information.
The request must include a report of the findings from
evaluations and a current plan for treatment. Review for medical necessity will
be performed on the information sent by the provider. This information must
substantiate the need for the child to receive services in a multidisciplinary
CHMS clinic.
B. Prior
Authorization Review Process
1. Prior
authorization requests are initially screened by a CHMS review coordinator (a
registered nurse). When complete documents are received, a prior authorization
review of the requested services is performed. If the CHMS review coordinator
cannot approve all of the services requested, the review is sent to a pediatric
physician advisor for determination.
2. When the request is approved, a prior
authorization number is issued along with a preliminary length of service,
procedure codes and units approved. Approval notifications are mailed to the
CHMS provider and the Medicaid beneficiary.
C. For any request that is denied or approved
at a reduced level, a letter containing case specific rationale that explains
why the request was not approved is mailed to the beneficiary and to the
Medicaid provider. These notification letters also contain information
regarding the beneficiary and provider's due process rights.
D. Providers may request reconsideration.
Requests must be received within 35 (thirty-five) days from the date of the
determination. Requests must be made in writing and include additional
information to substantiate the medical necessity of the requested services.
Reconsideration review will be performed by a different physician
advisor.
E. The prior
authorization/reconsideration process will be completed within 30 (thirty)
working days of receipt of all required documentation. Intervention/Treatment
Services may begin prior to the receipt of prior authorization
only at the financial risk of the CHMS organization.
F. The Medicaid beneficiary, the CHMS
provider, or both may request a fair hearing of a denied review determination
made by the Arkansas Foundation for Medical Care (AFMC). The fair hearing
request must be in writing and received by the Office of Appeals and Hearings
section of The Department of Human Services (DHS) within 35 (thirty-five)
calendar days of the date on the denial letter.
Refer to the flow chart in Section
244.000 of this manual for the
process outlined above.
244.000
Flow Chart of Intake and Prior
Authorization Process for
Intervention/Treatment
View or print Flow Chart of Intake and Prior
Authorization Process for Intervention/Treatment.
View or print AFMC CHMS Request for Prior
Authorization Form and instructions for completion.
Section V Provider Manual Update Transmittal
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