Common use of Authorization of Services Clause in Contracts

Authorization of Services. a. Inpatient and IMD Services – Acute Inpatient Hospital and IMD Clients shall meet medical necessity for treatment per DHCS Concurrent Review requirements. CONTRACTOR shall be responsible for reimbursing attending psychiatrists at both acute inpatient hospitals and IMDs. Claims for services for these Clients shall be processed in accordance with the following: 1) Acute Psychiatric Hospitals and IMDs – Attending psychiatrists shall be reimbursed by FFS rates set by CONTRACTOR and agreed to by COUNTY. 2) CONTRACTOR shall not reimburse attending physicians for services at IMDs designated as COUNTY contracted as services are inclusive in the facility charges. 3) CONTRACTOR must ensure that no reimbursement of IMD services is made for Clients 22 – 64 years of age. 4) CONTRACTOR must ensure that it does not reimburse for more than one (1) professional service per day without prior authorization. 5) CONTRACTOR must ensure that psychiatrist’s claims are appropriately adjudicated, and services rendered support billed CPT codes. b. Out of County Treatment Authorization 1) CONTRACTOR may accept claims for authorized outpatient Specialty Mental Health Services by any out of County provider that has completed a single case agreement with CONTRACTOR. 2) CONTRACTOR shall monitor claims payments to non-contracted out of County providers for outpatient Specialty Mental Health Services billed to CONTRACTOR. Any out of County provider meeting this criterion shall be advised in writing by CONTRACTOR that the cumulative claims exceeding $1,000 shall be denied unless provider becomes a Network Provider in CONTRACTOR’s network. CONTRACTOR shall also advise Network Providers that they must obtain authorization from CONTRACTOR for ongoing services. These services shall be authorized following the in-county benefit guidelines. 3) Children and adolescent Clients shall be allowed up to fifteen (15) visits for medication management; one (1) assessment visit, one (1) hour in duration; and fourteen (14) follow-up visits, fifteen (15) minutes in duration. 4) CONTRACTOR shall authorize up to twenty-six (26) therapy visits over a six (6) month period. The type of therapy; Individual, Group, or Family therapy; shall be at the discretion of the Network Provider. c. Eating Disorder Residential, Intensive Day and Outpatient Services – Eating Disorder Clients shall meet medical necessity for treatment per DHCS. CONTRACTOR shall be responsible for reimbursing provider contracted services at Residential, Intensive Day and Outpatient levels of care. Claims for services for these Clients shall be processed in accordance with the following:

Authorization of Services. a. Inpatient and IMD Services – Acute Inpatient Hospital and IMD Clients shall meet medical necessity for treatment per DHCS Concurrent Review requirements. CONTRACTOR shall be responsible for reimbursing attending psychiatrists at both acute inpatient hospitals and IMDs. Claims for services for these Clients shall be processed in accordance with the following: 1) Acute Psychiatric Hospitals and IMDs – Attending psychiatrists shall be reimbursed by FFS rates set by CONTRACTOR and agreed to by COUNTY. 2) CONTRACTOR shall not reimburse attending physicians for services at IMDs designated as COUNTY contracted as services are inclusive in the facility charges. 3) CONTRACTOR must ensure that no reimbursement of IMD services is made for Clients 22 – 64 years of age. 4) CONTRACTOR must ensure that it does not reimburse for more than one one (1) professional service per day without prior authorization. 5) CONTRACTOR must ensure that psychiatrist’s claims are appropriately adjudicated, and services rendered support billed CPT codes. b. Out of County Treatment Authorization 1) CONTRACTOR may accept claims for authorized outpatient Specialty Mental Health Services by any out of County provider that has completed a single case agreement with CONTRACTOR. 2) CONTRACTOR shall monitor claims payments to non-contracted out of County providers for outpatient Specialty Mental Health Services billed to CONTRACTOR. Any out of County provider meeting this criterion shall be advised in writing by CONTRACTOR that the cumulative claims exceeding $1,000 shall be denied unless provider becomes a Network Provider in CONTRACTOR’s network. CONTRACTOR shall also advise Network Providers that they must obtain authorization from CONTRACTOR for ongoing services. These services shall be authorized following the in-county benefit guidelines.services 3) Children and adolescent Clients shall be allowed up to fifteen (15) visits for medication management; one (1) assessment visit, one (1) hour in duration; and fourteen (14) follow-up visits, fifteen (15) minutes in duration. 4) CONTRACTOR shall authorize up to twenty-six (26) therapy visits over a six (6) month period. The type of therapy; Individual, Group, or Family therapy; shall be at the discretion of the Network Provider. c. Eating Disorder ResidentialIf a Client is identified through CONTRACTOR’s automated UM monitoring report as continuing or exceeding treatment allowed in Services Paragraph of this Exhibit A to the Contract, Intensive Day and Outpatient Services – Eating Disorder Clients shall meet an Access Line clinician will conduct additional review and/or assessment via Continued Care Review (CCR) to determine medical necessity for and level of care remain appropriate to the Clients’ needs and the planned treatment per DHCS. CONTRACTOR shall be responsible for reimbursing provider contracted services at Residential, Intensive Day will potentially improve Clients’ condition and Outpatient levels level of care. Claims for services for these Clients shall be processed in accordance with the following:functioning.

Authorization of Services. a. Inpatient and IMD Services – Acute Inpatient Hospital and IMD Clients Beneficiaries shall meet medical necessity for treatment per DHCS Concurrent Review requirements. Beneficiaries located in the IMDs have met medical necessity and COUNTY admission criteria for treatment, therefore no additional review of authorization for these IMD services are required by CONTRACTOR. CONTRACTOR shall be responsible for reimbursing attending psychiatrists at both acute inpatient hospitals and IMDs. Claims for services for these Clients Beneficiaries shall be processed in accordance with the following: 1) Acute Psychiatric Hospitals and IMDs – Attending psychiatrists shall be reimbursed by FFS rates set by CONTRACTOR and agreed to by COUNTY. 2) CONTRACTOR shall not reimburse attending physicians for services at IMDs designated as COUNTY contracted as services are inclusive in the facility charges. 3) CONTRACTOR must ensure that no reimbursement of IMD services is made for Clients 22 – 64 years of age. 4) CONTRACTOR must ensure that it does not reimburse for more than one one (1) professional service per day without prior authorization. 53) CONTRACTOR must ensure that psychiatrist’s claims are appropriately adjudicated, and services rendered support billed CPT codes. CONTRACTOR is required to develop a post service auditing and review process by which to determine claims submitted are supported by clinical documentation to meet administrative requirement for showing evidence of medical necessity in the medical record. b. Out of County Treatment Authorization 1) CONTRACTOR may accept claims for authorized outpatient Specialty Mental Health Services by any out of County provider that has completed a single case agreement with CONTRACTOR. 2) CONTRACTOR shall monitor claims payments to non-contracted out of County providers for outpatient Specialty Mental Health Services billed to CONTRACTOR. Any out of County provider meeting this criterion shall be advised in writing by CONTRACTOR that the cumulative claims exceeding $1,000 shall be denied unless provider becomes a Network Provider in CONTRACTOR’s network. CONTRACTOR shall also advise Network Providers that they must obtain authorization from CONTRACTOR for ongoing services. These services shall be authorized following the in-county benefit guidelines. 3) Children and adolescent Clients Beneficiaries shall be allowed up to fifteen (15) visits for medication management; one (1) assessment visit, one (1) hour in duration; and fourteen (14) follow-up visits, fifteen (15) minutes in duration. 4) CONTRACTOR Contractor shall authorize up to twenty-six (26) therapy visits over a six (6) month period. The type of therapy; Individual, Group, or Family therapy; shall be at the discretion of the Network Provider. c. Eating Disorder ResidentialIf a Beneficiary is identified through CONTRACTOR’s automated UM monitoring report as continuing or exceeding treatment allowed in Services Paragraph of this Exhibit A to the Contract, Intensive Day and Outpatient Services – Eating Disorder Clients shall meet an Access Line clinician will conduct additional review and/or assessment via Continued Care Review (CCR) to determine medical necessity for and level of care remain appropriate to the beneficiaries needs and the planned treatment per DHCS. CONTRACTOR shall be responsible for reimbursing provider contracted services at Residential, Intensive Day will potentially improve beneficiaries condition and Outpatient levels level of care. Claims for services for these Clients shall be processed in accordance with the following:functioning.

Authorization of Services. a. Inpatient and IMD Services – Acute Inpatient Hospital and IMD Clients Beneficiaries shall meet medical necessity for treatment per DHCS Concurrent Review requirements. Beneficiaries located in the IMDs have met medical necessity and COUNTY admission criteria for treatment, therefore no additional review of authorization for these IMD services are required by CONTRACTOR. CONTRACTOR shall be responsible for reimbursing attending psychiatrists at both acute inpatient hospitals and IMDs. Claims for services for these Clients Beneficiaries shall be processed in accordance with the following: 1) Acute Psychiatric Hospitals and IMDs – Attending psychiatrists shall be reimbursed by FFS rates set by CONTRACTOR and agreed to by COUNTY. 2) CONTRACTOR shall not reimburse attending physicians for services at IMDs designated as COUNTY contracted as services are inclusive in the facility charges. 3) CONTRACTOR must ensure that no reimbursement of IMD services is made for Clients 22 – 64 years of age. 4) CONTRACTOR must ensure that it does not reimburse for more than one (1) professional service per day without prior authorization. 53) CONTRACTOR must ensure that psychiatrist’s claims are appropriately adjudicated, and services rendered support billed CPT codes. CONTRACTOR is required to develop a post service auditing and review process by which to determine claims submitted are supported by clinical documentation to meet administrative requirement for showing evidence of medical necessity in the medical record. b. Out of County Treatment Authorization 1) CONTRACTOR may accept claims for authorized outpatient Specialty Mental Health Services by any out of County provider that has completed a single case agreement with CONTRACTOR. 2) CONTRACTOR shall monitor claims payments to non-contracted out of County providers for outpatient Specialty Mental Health Services billed to CONTRACTOR. Any out of County provider meeting this criterion shall be advised in writing by CONTRACTOR that the cumulative claims exceeding $1,000 shall be denied unless provider becomes a Network Provider in CONTRACTOR’s network. CONTRACTOR shall also advise Network Providers that they must obtain authorization from CONTRACTOR for ongoing services. These services shall be authorized following the in-county benefit guidelines. 3) Children and adolescent Clients Beneficiaries shall be allowed up to fifteen (15) visits for medication management; one (1) assessment visit, one (1) hour in duration; and fourteen (14) follow-up visits, fifteen (15) minutes in duration. 4) CONTRACTOR shall authorize up to twenty-six (26) therapy visits over a six (6) month period. The type of therapy; Individual, Group, or Family therapy; shall be at the discretion of the Network Provider. c. Eating Disorder Residential, Intensive Day and Outpatient Services – Eating Disorder Clients shall meet medical necessity for treatment per DHCS. CONTRACTOR shall be responsible for reimbursing provider contracted services at Residential, Intensive Day and Outpatient levels of care. Claims for services for these Clients shall be processed in accordance with the following:fourteen

Authorization of Services. a. Inpatient and IMD Services – Acute Inpatient Hospital and IMD Clients shall meet medical necessity for treatment per DHCS Concurrent Review requirements. CONTRACTOR shall be responsible for reimbursing attending psychiatrists at both acute inpatient hospitals and IMDs. Claims for services for these Clients shall be processed in accordance with the following: 1) Acute Psychiatric Hospitals and IMDs – Attending psychiatrists shall be reimbursed by FFS rates set by CONTRACTOR and agreed to by COUNTY. 2) CONTRACTOR shall not reimburse attending physicians for services at IMDs designated as COUNTY contracted as services are inclusive in the facility charges. 3) CONTRACTOR must ensure that no reimbursement of IMD services is made for Clients 22 – 64 years of age. 4) CONTRACTOR must ensure that it does not reimburse for more than one (1) professional service per day without prior authorization. 5) CONTRACTOR must ensure that psychiatrist’s claims are appropriately adjudicated, and services rendered support billed CPT codes. b. Out of County Treatment Authorization 1) CONTRACTOR may accept claims for authorized outpatient Specialty Mental Health Services by any out of County provider that has completed a single case agreement with CONTRACTOR. 2) CONTRACTOR shall monitor claims payments to non-contracted out of County providers for outpatient Specialty Mental Health Services billed to CONTRACTOR. Any out of County provider meeting this criterion shall be advised in writing by CONTRACTOR that the cumulative claims exceeding $1,000 shall be denied unless provider becomes a Network Provider in CONTRACTOR’s network. CONTRACTOR shall also advise Network Providers that they must obtain authorization from CONTRACTOR for ongoing services. These services shall be authorized following the in-county benefit guidelines. 3) Children and adolescent Clients shall be allowed up to fifteen (15) visits for medication management; one (1) assessment visit, one (1) hour in duration; and fourteen (14) follow-up visits, fifteen (15) minutes in duration. 4) CONTRACTOR shall authorize up to twenty-six (26) therapy visits over a six (6) month period. The type of therapy; Individual, Group, or Family therapy; shall be at the discretion of the Network Provider. c. Eating Disorder ResidentialIf a Client is identified through CONTRACTOR’s automated UM monitoring report as continuing or exceeding treatment allowed in Services Paragraph of this Exhibit A to the Contract, Intensive Day and Outpatient Services – Eating Disorder Clients shall meet an Access Line clinician will conduct additional review and/or assessment via Continued Care Review (CCR) to determine medical necessity and level of care remain appropriate to the Clients’ needs and the planned treatment will potentially improve Clients’ condition and level of functioning. 1) The CCR involves consultation with Network Providers and shall include, at a minimum, a statement of presenting problems including diagnosis, justification for extended services, a brief treatment per DHCSplan including the number of additional requested services to resolve the problem, treatment goals, as well as information relevant to the specific diagnosis, mental status, symptomatology, functional impairment, and a description of linkages to other community resources and support groups. CONTRACTOR The CCR also may involve rescreening the Client which, if applicable, shall be responsible for reimbursing provider contracted services include, at Residentiala minimum, Intensive Day and Outpatient levels determination of appropriate level of care. Claims for services for these Clients shall be processed , functional limitations and treatment barriers, service verification, identification of unmet resource needs and self-report measure of treatment effectiveness and satisfaction. 2) If the Access Line clinician determines the Client no longer meets Specialty Mental Health criteria, a transition of care to the MCP is facilitated by CONTRACTOR in accordance coordination with the following:MCP. 3) If the Access Line clinician determines the Client may require COUNTY level of care and may be better served by COUNTY, the Client may be referred and linked to COUNTY for further assessment. If COUNTY assessment determines COUNTY level of care is not appropriate, COUNTY reserves the right to refer back to CONTRACTOR for services. 4) With approval from ADMINISTRATOR, the utilization process can be modified and/or replaced by other similar systems that authorize more hours of treatment than initially allowed to a Client provided that justification includes utilizing the minimum criteria detailed in the Services Paragraph of this Exhibit A to the Contract. 5) Access Line clinicians shall utilize Medical Necessity criteria and as needed, consultations with designated COUNTY staff to guide the screening for medical necessity and appropriateness of mental health services.