Provider Manual

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INFORMATION REQUIRED FOR SERVICE AUTHORIZATION

Guidelines for Inpatient | Guidelines for Stay Reviews | Guidelines for Discharge

Carelon shares with providers the common goal of delivering care that is most appropriate given the severity of illness and intensity of service. A review of current clinical data is required for all levels of care. The initial review should identify problems requiring treatment at the identified level of care, the treatment approach that will be used to resolve the current problems and an identification of objectives by which to monitor progress, including length of stay. Further reviews should focus on a solution-oriented response to treatment, any revisions in the treatment plan and the discharge or follow-up plan. When you call, be prepared to discuss the following with our Service Management staff to facilitate this process. Similarly, your internal documentation should contain the same type of information to facilitate the review process.

Documentation Guide – Procedure for Inpatient

  1. All clinical reviews completed at the time of the initial request for care will be documented in the CareConnect. Concurrent reviews will also be documented in the system.
  2. The following information, as relevant, will be gathered telephonically with as much detail as the informant is able to provide:

IP

DOCUMENTATION GUIDELINES FOR INPATIENT

Pre-Certification

Contact Screen:

  1. Contact Name / Phone Number
  2. Member and Provider Search

Request Screen:

  1. LOC
  2. Type of service
  3. Admit date and requested start date need to be the same

Level of Care:

  1. Type of review
  2. Members location
  3. Who prompted the admit (Primary referral source)
  4. Medically cleared by? Phone number (admitting physician)
  5. Attending physician? Phone number (attending physician)

Diagnosis:

  1. Behavioral Diagnosis (ICD Code and Description)
  2. Medical Diagnosis
  3. Social Elements Impacting Diagnosis
  4. Optional – Functional Assessment (Assessment and Score)

Current Risks:

  1. Precipitant
  2. 201/302
  3. Describe the precipitant
  4. Duration of symptoms
  5. Stressors
  6. Supports
  7. Marital status
  8. Risk to self
  9. Risk to others
  10. Inside the suicide/homicide complex department:
    1. Current ICM/RC?TCM/ISC
    2. If current ICM, have they been notified
    3. Does member need BSU/ICM Referral
  11. Previous history of SI/HI? If yes describe in SI/HI complex
  12. If suicide attempt – did the member need medical treatment?
  13. Did member account for his/her rescue? (who brought in today)
  14. Was member under the influence of chemicals? (UDS/BAL)

Current Impairments:

  1. Mood disturbance
  2. Orientation
  3. Change in sleep
  4. Change in appetite weight loss w/eating disorder – 2 or 3 need to quantify with complex
  5. Anxiety
  6. Medical/physical/conditions
  7. Psychosis – 1, 2, or 3 requires complex completion
  8. Substance abuse/dependence
  9. Thinking/cognition/memory/concentration problems
  10. Job/school performance problems
  11. Impulsive/aggressive/reckless/marital/family problems
  12. ADL’s
  13. Legals
  14. Under 19 complex: required IF Child/Adolescents in school and under 21.
  15. Over 65 Complex required if age appropriate

Treatment History:

  1. Mental health in past 12 months – check all that apply and rate
  2. Substance abuse treatment in past 12 months – check all that apply and rate
  3. Treatment compliance (non-medication)
  4. Is member currently on medications? – non compliant would = yes
  5. Is member currently on medication for Axis III
  6. List medications for Axis III, if applicable
  7. Labs
  8. Pregnancy
  9. PCP

Psychotropic Medications:

  1. List all Psychiatric medications, identify compliance (adherence), side effects & prescriber. (use free text if more than 4)

Substance Abuse:

  1. Check and clarify all which are indicated – If current impairment was listed at 2-3 , at least one substance is required
  2. UDS and BAL if not gathered previously
  3. Withdrawal symptoms – check all that apply if + UDS or BAL (current or past)
  4. Vitals if + UDS or BAL
  5. If + UDS or BAL – request D/A evaluation, BSU referral
  6. Longest period of sobriety – required if + UDS/BAL
  7. Relapse date – required if + UDS/BAL

Treatment Request:

  1. Planned discharge LOC
  2. Planned discharge residence
  3. Treatment plan

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SR

DOCUMENTATION GUIDELINES FOR STAY REVIEWS

Level of Care:

  1. Type of Review – (Concurrent Review)
  2. UR Contact name and phone number

Diagnosis:

  1. Behavioral Diagnosis (ICD Code and Description)
  2. Medical Diagnosis
  3. Social Elements Impacting Diagnosis
  4. Optional – Functional Assessment (Assessment and Score)

Current Risks:

  1. Review Precipitant-
  2. Re-evaluation of risk to self—complete discharge readiness measures and treatment plan to address safety
    1. **If no ICM has BSU referral been discussed
    2. ** If current ICM collateral gathered
  3. Assess ICM and Follow up recommendations
  4. Re-evaluation of risk to others—complete homicidal complex treatment plan and follow up recommendations.
  5. Evaluate gathered collateral information

Current Impairments:

  1. Re-evaluation of Mood Disturbance
  2. Re-evaluation of weight loss associated w/ ED
  3. Re-Evaluation of Anxiety
  4. Re- Evaluation of Medical/Physical conditions
  5. Re-Evaluation of Psychosis- if score 1-3 mandatory complex completion
  6. Re-Evaluation of substance Abuse /Dependence
  7. Re-Evaluation of Thinking/Cognition/Memory/Concentration problems
  8. Re-Evaluation of Job/School problems
  9. ** If school age: explore SAP involvement
  10. Re-Evaluation of Impulsive/Reckless/Aggressive behaviors
  11. Re-Evaluation of Social functioning
  12. Re-Evaluation of ADL’S
  13. Re-Evaluation of Legal
  14. Re-Evaluation of Under 19 complex if age appropriate
  15. Re-evaluation of Over 65 complex if age appropriate

Treatment History:

  1. **Collateral information from Outpatient
  2. ** History of State Hospitalizations
  3. Lab results
  4. Is the Member Currently on Psychotropic Medications
  5. Is Member currently on medications for physical condition?—only list if changed

Psychotropic Medications:

  1. Changes in medications? (add additional)
  2. Side effects
  3. Usually Adherent (compliant)
  4. Prescriber
  5. List discontinued medications
  6. Any lab results for Medications

Substance Abuse:

  1. Results of UDS/BAL if Pending
  2. Withdrawal Symptoms if UDS/Bal was +
  3. Vitals if UDS/BAL was +
  4. ** if UDS/BAL was + is MD addressing? – Free text
  5. ** if UDS/BAL was + has D/A referral been done—Free text

Treatment Request:

  1. Verify admit status- 201/302
  2. Primary Reason for Continued stay
  3. Primary Barrier to Discharge
  4. Baseline evaluation- check all that apply
  5. Expected Discharge Date
  6. Planned Discharge Level of Care
  7. Planned Discharge Residence
  8. Criteria met? – list
  9. ** Treatment Plan changes/Discharge Plan

Discharge

DOCUMENTATION GUIDELINES FOR DISCHARGE

Discharge Review:

  1. Actual discharge date
  2. Primary Discharge Diagnosis
  3. Discharge Condition
  4. Treatment Involved- check all that apply

Current Risks:

  1. Risk to Self- check all that apply
  2. Risk to Others- check all that apply

Current Impairments:

  1. Complete all 12 Impairments
  2. Total number sessions(days) used
  3. Discharge plan in place
  4. Actual Level of Care Discharged to
  5. Type of Discharge
  6. PCP notified?
  7. Actual Discharge Residence
  8. Member/Family name for Follow-up, Relationship and Telephone Number

Aftercare Follow-up Appts:

  1. Behavioral Health Provider
  2. * Prescribing Physician—CHECK “NOT ARRANGED” IF AT SAME PROVIDER
  3. Calculate Number of days to aftercare
  4. Within Timeframe

Follow Up:

  1. Follow Up Exemption—this would be yes if moving to another LOC, etc…
  2. Follow up Type(Routine, Intensive)*
  3. Date of First Follow-Up
  4. ** DA appt. if member had + UDS/BAL
  5. ** ICM referral made
  6. **if current ICM Name and Phone number
  7. **Coordination with Support Systems

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