Effective July 10, 2006 the maximum medication/somatic limits per authorization increases from 8 to 12 units. This change is effective July 10, 2006 and covers dates of service beginning July 1, 2006.
I. REQUEST FOR SUPPLEMENTAL UNITS
A MEDICATION/SOMATIC SERVICE-CSA’s may have consumers who are in need of more than 12 units of Medication/Somatic service in any given 90 day period. The following steps should be taken to process requests for additional Medication/Somatic units:
1. FOR REQUESTS OF 13 TO 32 UNITS OF MEDICATION/SOMATIC SERVICE
a. CSA representative calls AHL to request up to an additional 20 units of Medication/Somatic service on an existing authorization plan (up to a total of 32 units)
b. The Care Coordinator locates the eCura record and opens a “supplemental units request” event screen.
c. The Care Coordinator asks the CSA representative the following question: Has there been a change in psychiatric or somatic health status /condition within the past 30 days or other serious psychiatric / nursing need that necessitates more intensive psychiatric or nursing intervention?
d. If yes, indicate which of the following applies and describe the services to be provided:
1) Psychiatric decompensation or crisis
2) Discharge from an acute care setting (including crisis beds) within the past 30 days
3) Significant change in medications or psychiatrist in the last 30 days
4) Complex or serious medical problems requiring a higher level of intervention
5) Participation in a DCMAP structured psychiatric / nursing education program
e. If the answer is “yes” and reasonable justification demonstrating medical necessity is provided, the Care Coordinator will add up to 20 additional units of Medication / Somatic service to the existing authorization plan.
f. If the answer is “no” or reasonable justification is not provided, the request is pended for review by the Chief Clinical Officer.
2. FOR REQUESTS OF 33 OR MORE UNITS OF MED / SOMATIC SERVICE
a. Requests for 33 or more units of Medication / Somatic service require the following clinical documentation:
1) copy of most recent diagnostic assessment
2) copy of most recent IRP / IPC and ISSP
3) copy of encounter notes from the last three med/somatic visits
4) written justification demonstrating medical necessity for the requested units
b. The CSA will FAX the required documents to the Care Coordinator requesting concurrent medical review to make a decision regarding whether the request meets criteria for medical necessity at the proposed level of care.
c. AHL will forward the documentation to the medical reviewer who may want to speak with the CSA med / somatic staff member making the request.
d. A response will be provided back to the CSA within 7 business days.
