ilos-case-support by Vaya Health

Vaya Health

Case Support T1016U5 Service Case Support activities are for members and recipients, ages 3 and older, who do not have other services in place that deliver this type of clinical support and who need help coordinating Social Determinants of Health or healthcare services. The service is time-limited and designed to meet some of the broad healthcare, educational, vocational, residential, financial, social, and other non-treatment needs of the member/recipient but cannot duplicate services coverable under IDEA, the Rehabilitation Act, other formalized supports, or Tailored Care Management. The Case Support service includes the arrangement, linkage or integration of multiple services and providers involved in the member’s/ recipient’s care. Interventions include making referrals to enhanced service providers and following up to ensure services are initiated. Interventions may also include provision of supportive contacts, skill reinforcement and skill development through telephonic or other technology means. Interventions include coordinating treatment and connecting the member or recipient to community supports. These are interventions that would otherwise be provided through walk-in clinics or advanced access providers. Interventions may also be provided as a follow up after acute crisis episode when enhanced services are not clinically indicated. The following interventions may occur in addition to the above treatment interventions. Note that this is not an allinclusive list but includes some typical activities. • • • • • •

• • • • • • •

Activate referrals and connections to other providers Initiate bed finding/placement activities Assist in connection to housing resources Monitor member’s/recipient’s safety, medical and psychiatric status (beyond time spent in the clinical activities billed separately) Assist with access to food, hydration, and comfort items Provide Peer Support Specialist services to educate on Wellness Recovery Action Plans (WRAPs), Advance Directives, etc. (This is time-limited while at the clinic, but interventions may include linking the member or recipient to Peer Support Services for ongoing support). Provide community resource information Assist in benefit coordination, inclusive of assisting member or recipient to complete paperwork to apply for needed benefits Assist in applying for patient assistance programs for medication Assist in coordination with physical health providers including linkage and referral to these providers Identify natural supports and creative ways to maintain support system during special circumstances, which result in isolation Monitor as needed based on first evaluations where transfer to more intensive services is needed and is being coordinated Provide additional coaching and support to family members who are caregivers for the member or recipient to enhance their ability to meet member or recipient needs

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Page 2 of 7 The program is expected to help maintain members or recipients in the community and reduce the need for crisis intervention or a higher-level care. The service is delivered in a flexible manner to be meet the identified needs of the members or recipients. The goal is to provide individualized supports to the member or recipient to ensure behavioral stability and assess any social determinant of health needs and link the member or recipient to supports that can help address these such as food, medication, and technology for communication. Anticipated Outcomes • Decrease in the frequency/need for crisis intervention (use of Emergency Department, Mobile Crisis, and Facility Based Crisis) • Connection to supports that are able to assist in meeting the identified needs which may be beyond the MH/IDD/SUD treatment system such as food, shelter and supplies • Connection to benefits such as Social Security disability, unemployment, emergency resources available due to pandemic or other necessary resources

Service Exclusions This service may not be provided to members or recipients linked with enhanced services when these services are actively being provided. This service cannot duplicate services coverable under IDEA, the Rehabilitation Act, other formalized supports, or Tailored Care Management services. The provider is required to fulfill all TCM duties, including coordinating with physical health providers, with the exception of delivering interventions related to Healthy Opportunities and Prevention and Population Health Programs. A care coordinator may be assigned to the member to ensure there are no gaps in member care.

Service Frequency and Intensity Includes face-to-face, telephone time, telehealth contact with the member/ recipient, collateral, and other agency personnel. The frequency and amount of this service is based on the member’s or recipient’s needs. The activities must be directly related to support to the member or recipient and not strictly for administrative activities such as scheduling clinic appointments, appointment reminders, forwarding messages to staff, phone calls for cancellation of appointments, etc. • • • •

Staff travel time is not covered under this service. Preparation or completion of documentation such as service notes, time sheets, etc. is not covered under this service. Structured services including Evaluations, Outpatient Treatment/Habilitation or afterhours services are to be reported to the appropriate service type. This service cannot be utilized for members or recipients that have enhanced services in place, or services that are expected to provide case support activities, unless those services are temporarily unavailable due to unique circumstances such as those experienced during a pandemic.

Provider Requirements The provider delivering this service shall meet the following requirements: • Provider must meet qualification for participation in NC Medicaid and/or NC Health Choice program, be credentialed by the NC Division of Health Benefits, and be enrolled in NC Tracks. • Provider must be enrolled as a network provider in Vaya Health’s Closed Provider Network, in good standing, and Vaya Health | Case Support Copyright © 2023 Vaya Health. All rights reserved.

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Page 3 of 7 • •

contracted to deliver the service. Provider must verify employee/independent contractor qualifications at the time employee is hired/contracted. Providers must provide verification of staff qualifications on at least an annual basis. Provider must comply with all terms and conditions of the network contract with Vaya Health, other applicable written agreements, and all applicable federal, state, and local laws, rules, and regulations.

Staffing Requirements Administrative Supervision Requirements

Credentialing Process

Clinical Supervisor Requirements

Meets the requirements specified for Qualified Professional (QP, AP, CPSS, Paraprofessiona l) status according to 10A NCAC 27G.0104

Provider responsibility to ensure staff meet minimum standards

As specified in 10A NCAC 27G.0104; Supervision should be provided at the intensity required based on the level of staff providing the treatment and intervention, following the providers established policies for supervision of staff, and staff written supervision plans where these are required. Supervision can be provided virtually via phone or twoway audio/video as necessary to ensure that staff requiring supervision have access to support the members or recipients receiving Case Support services most effectively.

Provider must have an outlined training plan for paraprofessionals including escalation training for additional support by clinical staff when indicated.

Licensed Mental Health professional:

Clinicians associated with the program

As specified in 10A NCAC 27G.0104 and according to

Staff will have the same training as the service this is being

Title

Qualifications

Qualified Professional, Associate Professional or paraprofessional, including Certified Peer Support Specialist

Licensed Professional

Training

Staff will have the same training as the service this is being utilized in lieu of. Staff will still be required to provide only those services within the scope of their training. For example, a paraprofessional or Peer Support Specialist would not provide therapy interventions.

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Page 4 of 7 Licensed Psychologist, LCSW, LCMHC, LMFT or Associate level Clinicians

will be credentialed according to standard process.

licensure/certificatio n requirements of the appropriate discipline

utilized in lieu of. Staff will still be required to provide only those services within the scope of their training.

Member Eligibility Requirements To be eligible for Case Support, (a) the member (ages 3 and older) must have NC Medicaid or NC Health Choice based on residence in a county located within Vaya’s region or the recipient must be a resident of a county located with Vaya’s region and be eligible to receive State-Funded health care services through Vaya, (b) be enrolled in Vaya’s Behavioral Health and Intellectual/Developmental Disabilities Tailored Plan, and (c) meet the following criteria: • • •

There is a DSM-5 (or subsequent editions) diagnosis present, or the person has a developmental disability as defined at N.C.G.S. 122C-3 (12a), AND; Level of Care Criteria, LOCUS/CALOCUS, ASAM, or SNAP/SIS deemed eligible for services based on a documented developmental delay or disability, AND The member or recipient is experiencing difficulties in at least one of the following areas and there are no existing services that can meet their needs: o Has financial concerns but is unsure what resources may be available and needs assistance in accessing/identifying o Has unmet, identified needs from multiple agencies inclusive of, but not limited to, Social Services, Division of Juvenile Justice, school system, health care system o Needs advocacy and service coordination to direct service provisions from multiple agencies

Utilization Management Utilization management of covered services is a part of the assurance of medically necessary service provision. Authorization, which is an aspect of utilization management, validates approval to provide a medically necessary covered service to eligible beneficiaries. Prior Approval Requirements: Prior authorization is not required if a member is already linked to services with the provider, however post-service reviews may be conducted. Services are based upon a finding of medical necessity, must be directly related to the beneficiary’s diagnostic and clinical needs, and are expected to achieve the specific rehabilitative goals detailed in the beneficiary’s PCP. Medical necessity is determined by North Carolina community practice standards, as verified by Vaya, which will evaluate the request to determine if medical necessity supports more or less intensive services. Medically necessary services are authorized in the most cost-effective mode, as long as the treatment that is made available is similarly efficacious as services requested by the beneficiary’s physician, therapist, or other licensed practitioner. Typically, the medically necessary service must be generally recognized as an accepted method of medical practice or treatment. This service shall be covered when the service is medically necessary and: a. The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the member’s needs; Vaya Health | Case Support Copyright © 2023 Vaya Health. All rights reserved.

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Page 5 of 7 b. The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide;

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Page 6 of 7 c. The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the member, the member’s caretaker, or the provider; and d. The member meets and continues to meet the eligibility requirements for this service, and treatment goals have not yet been achieved. Services and interventions must be reviewed for effectiveness, and interventions should be modified, if necessary, so that the individual makes greater progress.

EPSDT SPECIAL PROVISION: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid beneficiary under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (includes any evaluation by a physician or other licensed practitioner). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his or her health in the best condition possible, compensate for a health problem, prevent it from worsening or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the beneficiary’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the beneficiary’s right to a free choice of providers. EPSDT does not require the state Medicaid agency to provide any service, product, or procedure: • That is unsafe, ineffective, or experimental or investigational • That is not medical in nature or not generally recognized as an accepted method of medical practice or treatment EPSDT does not apply to NC Health Choice members or State Funded Services recipients. EPSDT and Prior Approval Requirements If the service, product, or procedure requires prior approval, the fact that the beneficiary is under 21 years of age does NOT eliminate the requirement for prior approval. Important additional information about EPSDT and prior approval is found in the NC Tracks Provider Claims and Billing Assistance Guide and on NC DHHS: Early Periodic Screening, Diagnostic and Treatment Medicaid Services for Children. Service limitations on scope, amount, duration, frequency, location of service and other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider’s documentation shows that the requested service is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition” [health problem]; that is, provider documentation shows how the service, product or procedure meets all EPSDT criteria, including to correct or improve or maintain the beneficiary’s health in the best condition possible, compensate for a health problem, prevent it from worsening or prevent the development of additional health problem.

Documentation Requirements: A full service note that meets the requirements per APSM 45-2 is required for all dates of service. These services shall be properly and contemporaneously documented in accordance with this section and the DMH/DD/SAS Records Vaya Health | Case Support Copyright © 2023 Vaya Health. All rights reserved.

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Page 7 of 7 Management and Documentation Manual 45-2 (RMDM) prior to seeking reimbursement from Vaya Health. Regardless of the service type, significant events in an individual’s life that require additional activities or interventions shall be documented over and above the minimum frequency requirements. Providers shall make all documentation supporting claims for services reimbursed by Vaya Health available to Vaya Health, NCDHHS and CMS upon request. The note must include the activities performed and the agencies contacted, if applicable. For members with intellectual and/or developmental disabilities, a service grid that meets the requirements per APSM 45-2 can be utilized and for elements that are unable to be captured in the grid alone, detailed notes for each service date should be included that support the time spent. However, a daily note is preferred. Documentation must be maintained in the member’s medical record. If the services are delivered telephonically or through telehealth methods, the documentation must clearly support why this is the most appropriate service delivery method.

Claims-Related Information: Providers shall comply with the NC Tracks Provider Claims and Billing Assistance Guide, applicable Medicaid bulletins issued by the NC Division of Health Benefits (DHB), applicable NC Medicaid/NCHC Clinical Coverage Policies, this service definition, Vaya Health’s fee schedule and other requirements and any other relevant documents for specific coverage and reimbursement for Medicaid and NC Health Choice. 1. Claim Type: Professional (CMS-1500/837P transaction) billed through Vaya Health. 2. International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS): Provider(s) shall report the ICD-10-CM and Procedural Coding to the highest level of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for code description. A DSM-5 diagnosis or developmental disability must be present to bill for this service (see 42 CFR § 435.110). 3. Codes and Modifiers: Provider(s) shall report the most specific billing code that accurately and completely describes the procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description. If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code. 4. Billing Units: Providers bill this service on a unit basis. 1 unit = 15 minutes. 5. Place of Service: This service is provided in any location and can be provided via technology platforms that are appropriate for service delivery. 6. Prior Authorization: No prior authorization is required if members are already linked with the provider for services. 7. NC Tracks Enrollment: Providers must be enrolled through NCTracks and ensure valid NPIs, taxonomies, sites, zip code (+4) and all other provider demographic information provided to Vaya Health matches the information in NCTracks to bill Vaya Health and be reimbursed for this service. 8. Coordination of Benefits: Providers must file with primary payor(s) prior to submission of claims for payment to Vaya Health, if applicable. 9. Reimbursement: Vaya Health reimburses providers for clean claims for services rendered in accordance with this Service Definition.

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