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Prior Authorization Prior Authorization Presentation Transcript

  • Prior Authorization The Ohio Dept. of MRDD www.mrdd.ohio.gov Division of Medicaid Development & Administration Phone: (614) 644-7747 FAX: (614) 752-5303 Contact: [email_address] Last Revision Date: 11-20-07 Next
  • Prior Authorization
    • This interactive Power Point and its shortcut links will allow you to go directly to the information you choose. You may also simply go through the presentation slide by slide to get a complete overview of the prior authorization process.
    • There are some links that take you out of the slide show and to other locations on the web. Use the internet “back” button to return to the slide presentation.
    Next Last viewed
  • Table of Contents
    • Prior Authorization
    • PA Process and Overview
    • The PA Submission
    • The PA Review
    • Due Process
    • Hints & guidance
    • Supportive Topics
    • Index to Slides
    Overview Due Process Index Submission Support Topics The Review Hints Last viewed Next
  • PA Process & Overview
    • Purpose
    • Key Points
    • Responsible Parties
    • PA Overview
    • PA Simplified (Flow Chart & Timeline)
    • The ODDP
    • The Individual Services Plan (ISP)
    • Required Criteria —from the Administrative Rules
    Overview Due Process Index Submission Support Topics The Review Hints Last viewed Next
  • Purpose
    • To establish the procedure that individuals use when they believe their service needs exceed their Ohio Development Disability Profile (ODDP) funding range.
    • Note: The critical challenge to each of the participants in the PA process is to assure life safety, promote efficiency, statewide consistency, and quality services while facilitating concepts of self-determination and individual empowerment. These often competing pressures will help to assure an effective and fair funding system that serves Ohioans on the IO Waiver.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Key Points to PA
    • The goal of the PA process is to assure that an individual receives access to all waiver-funded services for which they have a need and are eligible. This is best accomplished when there is a partnership between individual/guardian and the county board to:
      • Thoroughly identify and document the individual’s strengths and service needs; and
      • To consider the various options through which the individual’s strengths can be utilized and their needs met.
    • The rule applies to Individual Options Waiver recipients (not Level 1 recipients).
    • PAs cover only one waiver span. They must be resubmitted for each waiver span where the costs exceed the individual budget range.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Responsible Parties
    • The Individual (or Guardian ) requests a PA based on the services identified on the ISP when the costs for providing those services exceeds the individual’s ODDP determined funding range.
    • The County Board of MRDD provides important information on the individual, his/her needs, funding range, and PA support.
    • ODMRDD reviews the completed packet of info that makes up the PA request and either approves the request or forwards it to ODJFS.
    • ODJFS is the final authority and will make the final determination on the PA request.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA Overview
    • PA occurs when an individual’s funding level is higher than the upper end of the funding range as determined by the ODDP
    • The procedure establishes the steps for individuals and their guardian to request amounts beyond this range.
    • Initial request is submitted to ODMRDD
    • ODMRDD will ask the County Board of MRDD to send additional information
    • Once all info is received, ODMRDD will review the packet
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA Overview
    • If there are questions or missing info, the ODMRDD reviewer will contact the County Board
    • At the point that ODMRDD has all of the needed information on the review, it has five days to approve the request or forward it to ODJFS
    • ODMRDD can only approve a request. If it cannot approve, then it must be sent to ODJFS for further review.
    • ODJFS can approve the request as submitted, deny the request, or approve a modified version of the request
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA - Simplified ISP Development Team discusses needs & waiver services Individual/guardian believe services above DDP range CB and Team believe service needs are above DDP range Service Plan Budget is developed CB Advises of PA Possibility Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA - Simplified Individual/guardian submits PA request to State CB assists in PA request & submits on behalf of Individual/Guardian MRDD receives request and notifies CB CB assists ind/guar with IRF application CB prepares and submits complete request packet to MRDD Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA - Simplified MRDD reviews packet MRDD requests clarification from CB ODMRDD issues Yes determination ODMRDD Determination CB submits needed info ODMRDD forwards to JFS for review Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA Timeline
    • ODMRDD—receives a PA from an individual or guardian.
      • It notifies the County Board immediately
    • The County Board prepares the PA submission for ODMRDD.
      • Five working Days
    • ODMRDD requests, as needed from the County Board, additional information for its PA review.
      • As efficiently as possible, the reviewer and County will correspond until the PA submission is complete.
      • Once ODMRDD has a completed PA with adequate supporting information, it will make its determination in five working days
    • ODMRDD either approves the request and notifies the county of its decision or
    • ODMRDD submits the complete PA to ODJFS for new review.
      • ODJFS has 10 business days to approve or deny the request.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • ODDP
    • The Ohio Developmental Disabilities Profile (ODDP) is an individual characteristic profile from which a standardized score is derived based on the service needs of the individual. The individual score is then compared to that of all other individuals statewide. A range of service costs is generated so that individuals with similar needs can access comparable waiver services throughout Ohio.
    • It is important that the ODDP accurately reflect the unique situation and characteristics of the individual in order to fairly consider appropriate services and justify their costs. As an individual’s needs change, the ODDP should be reviewed for its accuracy.
    • For more information on the ODDP, see the Handbook for Individuals and Families at:
    • http://odmrdd.state.oh.us/mrddlibrary/publications/oddphandbook.pdf
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • The Individual Service Plan
    • The ISP is the product of a team effort that involves the identification of:
      • the individual’s strengths and needs,
      • services to meet the needs,
      • the manner in which the services will be delivered and
      • How the services are reimbursed if applicable
    • The plan is intended to build abilities/skills and to maintain health, safety and welfare for the individual.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • The Individual Service Plan
    • SSA from the County Board need to use the ISP process to:
    • Educate the individual (guardian) and their family about the PA process. Help families understand available alternatives.
    • Assure that all services identified are supported by documentation that may include formal/informal evaluations, notes or other evidence regarding daily functioning and response to previously/currently provided services.
    • Assure that key information in the ISP is consistent with that found in the individual’s ODDP, evaluations, and other evidence or is clarified and properly updated.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • The Individual Service Plan
    • For Prior Authorization Reviewers, the ISP is the most critical indicator of needs & is the basis for consideration of a PA.
      • Information supporting the PA must be related to the named individual, not roommates, family members, caregivers, etc.
      • Services to be provided must be listed in the individual's ISP together with note of the frequency and duration at which they are to be provided.
      • Document attempts to consider service alternatives that meet needs and help to stay within the funding range. (submit this with the PA)
    • Note: Waiver eligible services, even if needed, can only be reimbursed by the waiver when they are specified on the ISP.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • The PA Submission
    • What the Individual/Guardian Does
    • What the County Board Does
    • Required Criteria
    • The PA Narrative
    • Mid-Span Changes
    • Supportive Topics
    • Index to topics
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • What the Individual/Guardian Does
    • The Individual Services Plan
    • Submission of a PA Request
    • PA Narrative
    • Due Process
    • Supportive Topics
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Individual PA Form Next Overview Due Process Index Submission Support Topics The Review Hints
    • Individual Request Form— from Web
    • http://odmrdd.state.oh.us/forms/medicaid/pa-irf.pdf
    • Eligibility for Prior Authorization The individual’s request must meet all of the required criteria (see Required Criteria)
    • Finances should consistently reference the full waiver span and match the budget calculation tool and PAWS.
    • Submit the PA timely and allow adequate PA processing time to avoid a funding shortfall
    • Printable form
    • Completing the form…
    Last viewed
  • Individual PA Form
    • Personal Information:
    • Assure consistency with all submission documents, i.e. name, numbers, addresses, etc.
    • Section 1:
    • Service —list all waiver reimbursed services from the proposed ISP.
    • Units— Make sure that the measurement time period is consistent in your calculation, e.g. entire waiver span, per week, daily, etc. Do not combine unlike services or multiple rates on one line.
    • Frequency— Identify how often the service occurs per unit above.
    • Ratio —Staff:Individuals
    • Total Cost
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Individual PA Form
    • Section 2—Waiver span:
    • Include here the dates for the entire waiver span, e.g. 7/1/07 to 6/29/08.
    • Note: These dates should not be outside of the waiver span.
    • Section 3—Why is PA requested?:
    • A narrative explanation as to why the PA is requested is needed here. Be sure that it is consistent with the ISP and supporting documentation. Use additional paper if needed.
    • Signatures:
    • All PA forms must be signed as indicated and submitted as listed at the bottom of the form.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • What the County Board/SSA Does
    • The Individual Services Plan
    • Submission of Documents
    • Forms & Checklists
    • PA Narrative
    • Budget Documents
    • Required Criteria
    • Supportive Topics
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Forms & Checklists
    • Individual Request Form - Prior Authorization of Individual Options Waiver Services. (Appendix 4)
    • Open form…
    • County Board Checklist for Prior Authorization. (Appendix 5) Open checklist…
    • Budget Information or 20/20 -(Attachment A)
    • sample budget form…
    • County Board Approval Criteria form Open form…
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • County Checklist
    • Gather all relevant items from this checklist before submission in order to assure a timely response.
    • Submit the checklist with the PA packet.
    • Printable form
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • “ Medical Necessity” Criteria
    • In order to be approved by either ODMRDD or ODJFS, an individual’s request must meet all four of the following “medical necessity” criteria:
    • Services are appropriate to the individual’s health & welfare needs, living arrangement, circumstances and expected outcomes, AND
    • Services are of an appropriate type, amount duration, scope and intensity, AND
    • Services are the most efficient and effective services that when combined with other non-waiver services ensure the health and welfare of the individual receiving the services, AND
    • Services are necessary to protect the individual from substantial harm expected to occur if the requested services are not authorized.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Required Criteria
    • ODMRDD can approve a PA only if, in addition to the four Medical Necessity criteria being met, at least one of the following seven criteria are met:
    • Episodes of injury to self or others that have occurred within the last three months when there is a continuing risk of injury to self or others
    • 2. Presence of consistent behaviors in which the individual displays all of the following:
    • a) Lacks impulse control, and
    • b) Exhibits purposeful, dysfunctional goal-directed behavior to
    • obtain or avoid something, and
    • c) Requires constant monitoring and continual redirection
    • and/or behavioral intervention.
    • Helpful PA Evidence for these criteria
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Required Criteria
    • At least one of the following 7 criteria must be met (Cont’d):
    • 3. Presence of a progressive medical condition or a mental illness that is generally associated with:
      • Behaviors posing a risk to self or others, and
      • Requiring a controlled environment to maintain health and welfare
    • Presence of a medical condition which, without staff intervention, would threaten the individual’s medical stability.
    • Helpful PA Evidence for these criteria
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Required Criteria
    • At least one of the following 7 criteria must be met (Cont’d):
    • Inability of an unpaid caregiver to provide previous levels of support or to provide the level of support currently required
    • Alterations in staffing ratios resulting from circumstances beyond the control of the individual. Examples could be loss of roommate or a change in vocational schedule.
    • Helpful PA Evidence for these criteria
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Required Criteria
    • At least one of the following 7 criteria must be met (Cont’d):
    • An emergency situation that creates for an individual a risk of substantial self-harm or substantial harm to others if action is not taken within 30 days. An emergency may involve:
      • Abuse, neglect or exploitation of the individual, or
      • Health and welfare conditions that pose a serious risk to the individual or others, including immediate harm or death, or
      • Changes in the emotional or physical condition of the individual that necessitate substantial accommodations that cannot be reasonably provided by the individual’s caretaker.
      • Helpful PA Evidence for these criteria
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Criteria Evidence
    • Suggested Submission Evidence
    • A current, signed Behavior Support Plan (if applicable), and/or identify why there is no Behavior support plan when the PA is based on the existence of the consistent problem behaviors.
    • As applicable, MUI’s, Incident Reports, examples of specific incidents, frequency of incidents, time and/or location when incidents occurred, staff notes, patterns identified, etc.
    • 1. Episodes of injury
    • Identify any medical interventions and/or causes that may be applicable.
    • 2. Presence of consistent behaviors
    • Make sure all three parts of this criteria are met.
    • Specifically identify the eligibility criteria for the Behavior Support Add-on and discuss how it specifically applies to the individual.
    • Describe how the behaviors are identified as “consistent”.
    • Identify how behaviors are addressed across all life areas (ie., home, workshop, community, etc) to illustrate a consistent approach to behaviors.
    • Specifically identify how behaviors jeopardize the individual’s health and safety.
    • Describe how the behaviors are connected to the staffing needs requested.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Criteria Evidence
    • Submission Evidence:
    • Clearly identify the specific “medical condition” or “mental illness”.
    • Include any physician orders, staff notes, or other documentation to support criteria.
    • Describe how the medical condition is connected to the staffing needs requested.
    • Describe how the services for the medical condition are supported by other documentation.
    • Specifically identify the eligibility criteria for the Medical Support Add-on and discuss how it specifically applies to the individual.
    • Describe how staff intervention is necessary and what would happen if staff did not intervene.
    • 3. Progressive medical condition or a mental illness
    • Make sure both parts of this criteria are met.
    • Describe if the condition is controlled, degenerative, or progressive.
    • Describe how the behavior poses a risk to self or others.
    • Clarify why the “controlled environment” is necessary and how is it maintained.
    • 4. Threatening medical condition
    • Describe if the condition is controlled, degenerative, or progressive.
    • Describe how the medical condition threatens the individual’s medical stability.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • Criteria Evidence
    • Submission Evidence:
    • 5. Caregiver unable to provide support currently required
    • Provide specific details of when the unpaid caregiver previously provided services to the individual and how those services are now being administered.
    • Describe the reason the unpaid caregiver can no longer provide the same level of support.
    • Describe the types of natural supports available and the type of support they are able/willing to provide.
    • 6. staffing ratios changed
    • Specifically state when the alteration in staffing occurred.
    • Describe the efforts made by the county board to address the alteration at the time of occurrence, currently, and in the future.
    • Describe how the alteration that was beyond the individual’s control specifically affects the individual’s service needs.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Criteria Evidence
    • Submission Evidence:
    • An emergency situation creating risk of harm
    • Describe the basic circumstances surrounding the emergency situation.
    • Describe the immediate response from the county board to address the emergency situation and ensure the individual’s health and safety.
    • Describe the associated timeframes regarding the emergency
    • Describe efforts made by the county board to ensure the ODDP, ISP and budget documents are updated to reflect any long-term corrective action taken.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • PA Narrative
    • The County Board/SSA needs to give a narrative overview to explain the rationale for the PA request to help the reviewer. It should include:
    • what is being requested and why.
    • CB’s rationale for support or non-support of the PA request
    • CB’s rationale for any programmatic alternatives offered
    • Explanation of how individual meets each criteria marked in PA County Board Approval Criteria (Appendix 7)
    • Note: whether or not the CB supports the PA, the CB narrative needs to include how the program proposed or the alternatives offered meets the individual’s needs and fits the requirements of the PA rule.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • CB Approval Criteria To Table of Contents This form helps the ODMRDD reviewer know the extent of the County Board’s support that the individual meets critical criteria to qualify for prior authorization of IO waiver services. Please be sure your response on this form relates to the PA request rather than to the alternative options. Section 1 From the ODJFS rule 5101:3-41-12 on prior authorization and all are required to be eligible for approval Section 2 From the ODMRDD rule 5123:2-9-06 Waiver Methodology and in addition to all Section 1 criteria, at least one of the 7 conditions must apply to be eligible for approval by the ODMRDD To Page 2… Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • CB Approval Criteria Check the box if the County Board feels that needs can be met within the range determined by the ODDP and it disagrees with the PA request. The County Board should state in narrative form its reasons for supporting or not supporting the PA request. Printable form Page 2 Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • County Board Support
    • The County needs to decide and to indicate:
    • That it supports the PA request, or
    • That it does not support the PA and say why costs can be met within range, or   
    • That the CB has an alternate recommendation and the individual’s needs can be met within the ODDP range.
    • When the CB does not support the PA request, it needs to submit:
    • A clear statement as to why the CB does not think the PA request is needed
    • Details of its service alternatives with comments on how the service alternatives best meet the needs of the individual and the requirements of the rule
    • The alternative 20/20 or Finance Form
    • Evidence of its efforts to resolve dispute and reach agreement with individual
    • Evidence of its efforts to meet individual needs within the ODDP range.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Submission Content
    • Individual PA Request Form go to form..
    • County Board PA Checklist go to form..
    • Clear & Concise summary of situation
    • more on Narrative summary
    • Records of incidents if relevant
    • A description of the efforts the county board has made or plans for the future to ensure appropriate services are provided within the individual’s funding level.
    • Budget worksheet, 20/20, or Attachment A more info..
    • Current or proposed ISP
    • CB Approval Criteria Form more info..
    • go to form..
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Submission Content
    • Current & updated ODDP more info..
    • Relevant assessments, evaluations & support documentation as needed Behavior support plans
      • On site On call evaluation
      • Alone time evaluation
      • Medical Add-on
    • What not to send….
    • When the County Disagrees with the PA Request
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Mid-Span Changes & Emergencies
    • If reason for PA is loss of caregiver, give evidence that it is a recent concern
    • Other reasons may include change of roommate situation, unexpected needs or costs
    • Send a revised ISP or an addendum that discusses the emergency or mid-span situation and addresses the change in service
    • IF the emergency is significant consider an updated ODDP to see if there will be a corresponding increase in the range.
    • Even if the change is temporary, please submit budget information for the entire span
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • What not to Send
    • Copies of rules or MRDD procedures
    • Old Data not relevant to the current PA
    • Entire Charts for individual
    • Original documents that may be needed by individual at a later time
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Budget Documentation
    • Funding Range- -The ODDP determines the funding range in which your waiver services must fall. The funding range gives you dollars to fund the waiver services and supports you want and need. These services must ensure your health and safety.
    • Funding Level-- The individual Service Plan (ISP) determines your actual funding level. The services that you need regardless of the funding source will be identified on your ISP. The annual cost of your waiver services must be within or below the funding range. If an individual requires and has an approved PA, he/she can only spend up to the PA allowed over ODDP determined cap funding level. Any costs above that specifically approved in the PA approval would trigger a new PA
    • Funding Add-Ons-- The rate for routine homemaker/personal care (HPC) can be increased for individuals who meet certain medical and/or behavior criteria. See Behavior and Medical Add-ons
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Budget Documentation
    • Submit the individual’s budget form or 20/20. See the link below for an ISP budget form option-- from ODMRDD web page:
    • http://odmrdd.state.oh.us/forms/medicaid/pa-bi.pdf
    • Be sure ISP costs are consistent throughout the PA documents, e.g. IRF, PAWS, and finance forms.
    • Be sure the waiver span costs are for the entire span and try to avoid mixing weekly, monthly and total span costs.
    • Be sure that the waiver costs listed on the budget document and the PA request list all costs in the ISP including home modifications, etc and not just services driving the cost overrun.
    • Double check all math and cost listings.
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Hints & Guidance
    • Applicable Rules
    • Best Practices
    • Avoiding Delays
    • Additional Hints
    • Managing Plan Costs
    • Supportive Topics
    • Index to topics
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Applicable PA Rules
    • 5101:3-41-12—Prior Authorization Requirements
    • http://codes.ohio.gov/oac/5101%3A3-41-12
    • 5123:2-9-06-HCBS Waivers - Waiver Reimbursement Methodology
    • http://codes.ohio.gov/oac/5123%3A2-9-06
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Best Practices
    • Organize PA Packet
      • Cover page, table of contents, etc.
      • Submit a concise but clear narrative overview
      • Label supporting documentation
    • Only include PA relevant information
    • Develop a PA review committee in order to:
      • review all PA requests from an objective perspective,
      • review all efforts made to provide services within the designated funding range,
      • provide suggestions and alternatives
    Next Overview Due Process Index Submission Support Topics The Review Hints Last viewed
  • Avoiding Errors/Delays
    • Assure Consistency through all documents, ODDP, Diagnoses, ISP, BSP, & PA request
    • Make sure costs figures match in budget, IRF, proposed PAWS
    • Avoid mixing span, weekly, daily, calculation totals in budget figures
    • Assure BSPs are included when behavior is reason for PA
    • Send updated information
    • Include On-Site/On-Call & Alone Time evaluations when appropriate.
    • Make sure that behaviors and circumstances that match criteria reflect current situations
    • Review the submission for inconsistencies before submission.
    • When the county submits a revised PA request form with cost corrections from the original, be sure the new one is signed by the individual or guardian.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • Managing Plan Costs
    • Rationale:
    • PA was designed to ensure efficient and effective services.
    • ISP team members need to assure that individuals’ health and safety is provided through the most efficient and effective treatment objectives and, when possible, stay within the ODDP Funding Range
    • ISP team members need to determine if alone time, On-Site/On-call, or natural supports are appropriate to the individual's needs and, if so, whether such changes bring the cost of waiver services within or closer to the individual's ODDP determined funding cap.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • Managing Plan Costs
    • ISP Team Considerations for Reducing Costs:
    • Shared staffing
    • Decreased one-on-one time
    • Explore schedule changes that may change staffing ratios
    • Determine if a Personal Response System or other devices could be used as an alternative to direct supervision
    • Reduce and/or prioritize other waiver services (i.e., mileage, social services, respite care, etc.)
    • Determine if State Plan Home Health Services (formerly known as Core) or Private Duty Nursing (PDN) services could be used for certain medical needs
    • Explore the option of a roommate or a change in living situation
    • Explore the cost savings associated with utilizing an agency versus independent provider.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • Additional Hints
    • Make sure there is a clear statement of the concern or change in circumstance that resulted in the PA request
    • Include OSOC & Alone Time evaluations when appropriate
    • Document and submit efforts made by the county board to bring the individual within the assigned funding range.
    • Plan the scheduling of the ISP and budget timely to allow for the processing of a PA request and possible hearing.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • Additional Hints
    • For situations caused by a change in the daily structure or schedule including:
      • Individual no longer attends work or workshop
      • Individual needs or requests overnight staffing
      • There is a loss of natural supports
      • Individual cannot share services with others
    • Submit:
      • Explanation & evidence in the ISP of the problem
      • Documentation of individual needs and preference related to the change of circumstances.
      • Documentation of the County Board’s efforts to consider alternative program and/or staffing options.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • The PA Review
    • What ODMRDD Does
    • What ODJFS/BCA Does
    • Due Process
    • Supportive Topics
    • Index to topics
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • What ODMRDD Does
    • Once the required documents have been received by ODMRDD, notice is sent to the individual/guardian and/or authorized representative and the county board and it is assigned to a reviewer.
    • The reviewer will conduct an initial review of the information for basic adequacy, completeness and consistency.
    • The reviewer will perform a detailed analysis of the information submitted in the PA in order to assure that information is consistent, meets the criteria for Prior authorization in the rule, and the costs for the proposed services align with the approved rates and add-ons.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • What ODMRDD Does
    • The ODMRDD detailed review will include the following:
    • Consistency in assessing needs throughout ODDP, assessments and evaluations and in the ISP.
    • The PA request & documents for a clear indication of the services being requested, the time period it is needed, and their costs.
    • The services, costs and extent of need are consistently addressed and covered throughout all of the waiver span addressed by the PA
    • Assure that all services considered are appropriately listed in the ISP and service units and costs are consistent with the PA request.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • What ODMRDD Does
    • The ODMRDD Review will include the following:
    • When the CB does not agree with the PA, the CB alternative service plan will be considered similarly for consistency and effectiveness.
    • A review of the PA requested/CB alternative services along with the supporting data and assessments to assure they meet the four Medical Necessity criteria and any of the 7 MRDD required criteria.
    • Request of additional information from the CB if needed.
    Overview Due Process Index Submission Support Topics The Review Hints Next Last viewed
  • What ODMRDD Does
    • Once the information is deemed complete to make a determination:
    • ODMRDD must make its determination within 5 working days.
    • When ODMRDD approves the PA request, they will create a final approval correspondence & processes packet
    • When ODMRDD cannot approve the PA request, it will make its recommendation and forward a copy of the completed packet to ODJFS/BCA for its review.
    • NOTE: ODMRDD can only approve PA requests or refer them to ODJFS for further considerations.
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  • What ODJFS/BCA Does
    • Once ODJFS-Bureau of Community Access (BCA) receives a PA request packet from ODMRDD:
    • The PA packet will be reviewed for completeness per the CB checklist.
    • The packet must include a review form that includes a summary and recommendations from the ODMRDD review.
    • If required documents are missing, BCA will request them from ODMRDD and the County Board.
    • ODJFS has 10 working days from its receipt of the PA request to make its determination.
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  • What ODJFS/BCA Does
    • ODJFS/BCA will perform a detailed analysis of the complete packet for evidence to support the PA request similar to that done by ODMRDD.
    • If the documentation provided is not sufficient to permit determination by BCA, it will contact the CB and obtain whatever is needed.
    • If the BCA reviewer determines that the PA request warrant technical assistance due to high risk behaviors or conditions, it invite technical assistance staff from ODJFS or ODMRDD to help.
    • When concerns arise, the appropriate regulatory/monitoring agent may be notified and documented.
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  • What ODJFS/BCA Does
    • Once documentation is deemed sufficient to support a determination:
    • BCA convenes a QMRP Team Review and completes a subsequent Team Review form that documents the discussions, participants, evidence in support of the PA request, and the final ODJFS determination.
    • BCA records its decision in the in-house excel PA data bank relevant to the determination.
    • BCA prepares the paperwork relative to the final determination and forwards it to all parties affected by the decision.
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  • Due Process
    • The Individual/Guardian has the right to appeal any change in their services through the Department of Job and Family Services.
    • A change in service is defined as a reduction, denial or termination of service.
    • The individual’s hearing rights are provided with each final determination made by ODMRDD and ODJFS.
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  • Supportive Topics
    • ODDP
    • Behavior Add-On
    • Medical Add-On
    • Alone Time Evaluation
    • On-Site/On-Call
    • Index to topics
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  • Behavior Add-On
    • To receive the behavior support rate modification, the following conditions shall be met:
      • The individual must present a danger to self or others, or who has been assessed to have the potential to present a danger
      • A behavior support plan that is a component of the individual’s ISP has been developed.
      • The individual routinely receives clinical services from a licensed, certified or other type of professional who has specialized training or experience related to the design, development and implementation of the behavior support plan and the individual either;
        • Responds ‘yes’ to at least four items in question number thirty-two of the behavior domain of the ODDP, or
        • Requires a structured environment that, if removed, will result in the individual’s engagement in behavior destructive to self or others.
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  • Behavior Add-On
    • When determined through the ISP development process that the criteria contained in paragraph (D)(9)(b) of this rule has been met, the county board shall authorize the behavior support rate modification for routine HPC.
    • The department retains the right to review and validate the qualifications of any provider of clinical services identified in this paragraph.
    • ODJFS retains the final authority, based on the recommendation of the department, to review, revise and approve any element of the decision process resulting in a determination to make a behavior support modification to the HPC rate.
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  • Medical Add-On
    • The county board shall authorize the medical assistance rate modification when the following criteria have been met:
      • An individuals requires routine feeding and/or the administration of prescribed medications through gastrostomy and/or jejunostomy tubes, when the tubes are stable and labeled, and/or requires the administration of routine doses of insulin through subcutaneous injections and insulin pumps; or
      • An individual requires a nursing procedure or nursing task that a licensed nurse agrees to delegate in accordance with the rules contained in Chapter 4723-13 of the Administrative Code when such procedure or nursing task is not the administration of oral or topical medication or one of the health-related activities listed in paragraphs (L)(1) to (L)(8) of rule 5123:2-6-01 of the Administrative Code and provided in accordance with section 5123.42 of the Revised Code.
    • ODJFS retains the final authority, based on the recommendation of the department, to review, revise, and approve any element of the decision process resulting in a determination to make a medical assistance modification to the HPC rate.
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  • On-Site/On-Call
    • A provider is eligible to be reimbursed at the on-site/on-call payment rate for HPC services when:
      • The individual is asleep and does not require intervention or assistance during this time; and
      • The HPC provider is required to be on-site, but is not required to remain awake; and
      • Based upon assessed and documented need, the ISP indicates the days of the week and the beginning and ending times each day when it is anticipated that an individual will require on-site/on-call services; and
      • On-site/on-call time does not exceed any more than eight hours for the individual in any twenty-four-hour period.
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  • On-Site/On-Call
    • A provider shall be paid the routine HPC rate when an individual receives intervention/supports during the times the ISP indicates a need for on-site/on-call services. In these instances, the provider shall document the start and stop times and dates during which intervention/supports were provided to the individual.
    • NOTE: The above needs to be included in the ISP
    • When On-Site/On-Call is part of the cost calculation, please submit an OSOC assessment. The link below offers a sample tool .
      • To see a sample OSOC tool…
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  • On-Site/On-Call Overview Due Process Index Submission Support Topics The Review Hints Last viewed Next
  • Alone Time Assessment
    • It is helpful to document efforts to assess an individual’s need for supervision and ability to safely be unsupervised.
    • Some Counties have developed tools to evaluate individual’s ability to remain alone for extended periods of time.
    • Efforts of County Boards to conduct such assessments should be documented and submitted with the PA packet.
      • To see a sample tool…
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  • Alone Time Assessment Overview Due Process Index Submission Support Topics The Review Hints Last viewed Next
  • Links to forms
    • Prior Authorization Individual Request Form http://odmrdd.state.oh.us/forms/medicaid/pa-irf.pdf
    • County Board Checklist http://odmrdd.state.oh.us/forms/medicaid/pa-cbc.pdf
    • County Board Approval Form http://odmrdd.state.oh.us/forms/medicaid/pa-cb.pdf
    • Attachment A—Prior Authorization Budget Information http://odmrdd.state.oh.us/forms/medicaid/pa-bi.pdf
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  • ODMRDD Contacts
      • Prior Authorization—Dan Gazdik
        • [email_address] (614) 466-7747
      • Family Advocate—Peggy Martin
        • [email_address] (614) 466-8706
      • ODMRDD manuals and publications
        • http:// odmrdd.state.oh.us/mrddlibrary/public.htm
      • ODMRDD Phone Toll Free
        • (877) 464-6733
      • ODMRDD Web Home
        • http:// odmrdd.state.oh.us /
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  • Index to Topics Overview Due Process Index Submission Support Topics The Review Hints Last viewed First slide What not to send Timeline Table of Contents Rules Responsible Parties Purpose Required Criteria Forms Forms-printable Flowchart Budget Due Process Delays & errors to avoid CBMRDD CB Submission CB PA Authorization CB Checklist form CB approval form Best Practices Behavior Add-On Alone Time 20/20 PA Rules Overview On-Site/On Call ODMRDD ODJFS ODDP Mid-span Changes Medical Add-On Key Points Individual Request form (IRF) Individual Service Plan Individual Guardian Hints