Caring.�Serving.�Empowering.

Health Services for Childrenwith Special Needs, Inc.

(HSCSN)

Caring.�Serving.�Empowering.

Health Services for Childrenwith Special Needs, Inc.

(HSCSN)

ManualProvider

Table of Contents

About HSCSN 3 I. General Services 6

A. Provider Services 6 B. Provider Resources 6 C. Appointment Standards 7 D. Access Standards 8 E. Contracting 8 F. Provider Credentialing Process 9 G. Customer Care

i. Enrollment ii. Cultural Competency

11 12 12

H. Care Management 19 I. Family and Community Development (Outreach) Services 20 J. Claims and Billing

i. CMS 1500 ii. UB-04

22 25 27

II. Enrollee Benefits and Authorizations 56

A. Benefits and Pharmacy List 56 B. Overview of Care Coordination 64 C. Utilization Management

i. Referrals and Authorization of Services ii. Behavioral Health

iii. Appeals Process iv. Fair Hearing Process v. Medical Necessity Guidelines

66 66 70 74 75 76

III. Clinical Practice Standards 80

A. Primary Care and Specialty Services 80 B. HealthCheck (formerly EPSDT) 82 C. Supplemental Security Income (SSI) Program 85 D. Individuals with Disabilities Education Act (IDEA) 86 E. Adult Care 92 F. Vaccines for Children 92 G. Dental 93 H. Clinical Practice Guidelines 93 I. Advance Medical Directives 95 J. Mandatory Reporting 96

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IV. Quality Standards 97 A. Quality and Performance Improvement Program 97 B. External Quality Review Organization (EQRO) 99 C. Healthcare Effectiveness Data and Information Set (HEDIS®) 100 D. Satisfaction Surveys 104 E. Complaints 105 F. Grievances 106 G. Events (Sentinel, Critical, Never) and Unusual Incidents 107 H. Site Visits 113 I. Medical Record Documentation 115 J. Access to Provider Records 123 K. Access to Enrollee Records 124

V. Regulatory Standards 126

A. Corporate Compliance Program 126 B. Fraud, Waste and Abuse (FWA) 126 C. Audit and Oversight Activity 128 D. Provider Responsibilities 129

Appendix A – Forms 131

A. Provider Interest Form 132 B. Disclosure of Ownership 133 C. Behavioral Health Home Services Referral Form 137 D. Home Care Referral Form 139 E. Home Care Order 140 F. Personal Care Aide Referral Form 141 G. Personal Care Aide Assessment Form 142 H. Mental Health Screening Tool 147 I. OB Global Authorization and PsychoSocial Form 148 J. Unusual Incident Report 150 K. DC Medicaid Universal Referral Form 152 L. Early Intervention Disclosure Form 153

Appendix B – Acronyms 154

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About HSCSN The HSC Health Care System is a nonprofit health care organization committed to serving families with complex health care needs and eliminating barriers to health care services. The System combines the resources of a care coordination plan, a pediatric specialty hospital (The HSC Pediatric Center), a home health agency (HSC Home Care, LLC) and a parent foundation (The HSC Foundation) to offer a comprehensive approach to caring, serving and empowering individuals with disabilities. The System’s care coordination plan, Health Services for Children with Special Needs, Inc. (HSCSN), provides care to Supplemental Security Income-eligible youth and young adults in the District of Columbia through a care management network that provides a comprehensive set of benefits, including health, long-term care and social support services for members. HSCSN started as a demonstration pilot to serve Supplemental Security Income (SSI) beneficiaries and was incorporated in 1994 to develop a national model of managed care services for children and youth with complex health care needs. Today, HSCSN is a dedicated Medicaid health plan serving more than 5,800 children and young adults with disabilities. HSCSN provides services for eligible Medicaid recipients between birth and 26 years of age and has extensive experience in developing and managing services essential to achieving access to care for vulnerable populations. Utilizing a network of 2,000 providers, HSCSN coordinates all aspects of physical, mental, behavioral and developmental care and resources. Member advantages include traditional Medicaid benefits plus an array of expanded health care and wraparound services, such as individualized care management, 24-hour access to care coordination, outreach services, respite care and medically necessary home modifications. Each member has a care manager responsible for coordinating access to primary and specialty care, developing an individualized care plan, and educating the family on how to best prepare for care transitions. HSCSN is committed to helping members and their families reach their potential and lead more fulfilling lives by expanding access to health care and coordinating the delivery of comprehensive, cost-effective services.

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Health Services for Children with Special Needs, Inc. 1101 Vermont Avenue, NW, Suite 1200

Washington, DC 20005 www.hscsn-net.org

Main: (202) 467-2737 Fax: (202) 466-8514

Provider Services Questions and Concerns (202) 580-6483 – Ancillary Providers (202) 580-6480 – MDs

Customer Care Enrollee Assistance (Available 24/7) (202) 467-2737 1-866-937-4549 or (1-866-WE R 4 KIZ)

Verification of Enrollee Benefits/ Authorizations (202) 467-2737 1-866-937-4549

Language Line Interpretation Service for HSCSN Enrollees (202) 467-2737 1-866-937-4549 or (1-866-WE R 4 KIZ)

Laboratory Services Laboratory Corporation of America (LapCorp) 13900 Park Center Road Herndon, VA 20171 (703) 742-3100

Dental Benefits Quality Plan Administration (QPA) 7824 Eastern Avenue, NW # 100 Washington, DC 20012 (202) 722-2744 (202) 291-5703 fax QPA2000@aol.com

HSC Compliance and Ethics Hotline (202) 454-1223

Claims and Billing P. O. Box 29055 Washington, DC 20017 (202) 467-2737 (202) 467-0987 fax

District of Columbia Fraud, Waste and Abuse Hotline 1-877-632-2873

District of Columbia Ombudsman Hotline 1-877-685-6391

Pharmacy – CVS Caremark (480) 314-8695

Transportation – Southeastrans 1-866-991-5433

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National Committee for Quality Assurance (NCQA)

HSCSN has earned NCQA Organization Certification in Utilization Management (UM) and Credentialing/Recredentialing

NCQA Organization Certification indicates that an organization is well managed and delivers high quality care and service. Furthermore, Organization Certification requires organizations to consistently promote the adoption of strategies that will improve care, enhance service, and reduce costs. The NCQA UM Certification process encompasses 13 UM standards, two (2) standards addressing enrollee rights and responsibilities and one (1) in quality improvement (QI). UM Certification requirements assess key aspects of UM operations. These requirements focus on consumer protection and improvement in service to customers, including the following:

• Ensuring involvement of appropriate UM professionals • Making fair and timely medical necessity decisions • Handling enrollee appeals of medical necessity and coverage decisions in a fair and

timely manner • Measuring enrollee and provider satisfaction with the UM process • Improving operations through an internal QI process • Respecting enrollee rights throughout UM operations • Maintaining enrollee confidentiality when conducting UM functions

The NCQA Credentialing Certification process encompasses 11 Credentialing standards, four (4) standards addressing QI and one (1) protecting credentialing information. Credentialing Certification requirements assess key aspects of credentialing operations. These also focus on consumer protection and improvement in service, including the following:

• Ensuring a peer-review process for making credentialing decisions • Verifying credentials at time of initial and Recredentialing • Ongoing monitoring of sanctions and complaints • Improving operations through an internal improvement process • Allowing open practitioner-enrollee communications • Monitoring network adequacy, including availability (enough practitioners in each

geographic area) and accessibility (appointments with a practitioner) NCQA is a private, non-profit organization dedicated to improving health care quality and accredits and certifies a wide range of health care organizations. To learn more about NCQA, visit their website at www.ncqa.org.

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I. General Services

A. Provider Services HSCSN’s Provider Service staff is available to help your office with all Provider relation functions including but not limited to the following:

i. Training procedures for authorization and Claims payments;

ii. Assisting Providers to resolve billing and other administrative problems;

iii. Responding to Provider concerns about administrative processes;

iv. Assisting the Department of Health Care Finance (DHCF) in notifying

Providers of DHCF initiatives; and

v. Responding to Provider concerns about Enrollees.

B. Provider Resources

Visit the HSCSN website at www.hscsn-net.org to access an online Resource Center that provides access to pertinent information. From the home page navigation, click Provider Services, then Provider Resources.

Provider Manual

Provider Directory

Clinical Practice Guidelines

Mental Health Screening Tool

HealthCheck Periodicity Schedules

HealthCheck Provider Education System

HIV Resource Directory

Transportation Guidelines

Newsletters

Home-Based Behavioral Health Services

BH Home Services Referral Form

BH Home Service ISP Tool

BH Home Service Assessment Tool

OIG Notification

UM Authorization and Appeal Process

Authorization Update

Home Care Referral Form

Mental Health Provider Letter

Global Auth and PsychoSocial Form

General Services

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C. Appointment Standards

Access to medically necessary routine services is also monitored for the Medicaid population. Department of Health Care Finance standards regarding access to services include the following:

Enrollees with appointments who arrive by their scheduled appointment time shall not routinely be made to wait more than forty-five (45) minutes from their scheduled appointment time to see a PCP

PCPs shall offer new Enrollees an initial appointment within forty-five (45) days of their date of enrollment with the PCP or within 30 days of request, whichever is sooner

PCP’s must accommodate the need for evening and weekend appointments

Providers place of business must comply with the regulations outlined in the American Disabilities Act (ADA)

Providers office must be culturally competent and not discriminate against any enrollee based on cultural or religious background

Enrollees shall have access to services for the assessment and stabilization of psychiatric crises, including those experienced with treating CASSIP Eligible Enrollees on a twenty-four (24) hour basis, seven (7) days a week, including weekends and holidays. These services shall be provided by practitioners with appropriate expertise in mental health with on-call access to a pediatric or adolescent psychiatrist

Enrollees shall have access to 24 hour access to Urgent Care and Emergency Care seven (7) days a week, including weekends and holidays. Urgent Care will be provided directly by enrollee’s PCP or HSCSN would provide other arrangements.

Enrollees can utilize the HSCSN Toll free number 1-866-WE R 4 KIZ (937-4549) for a HSCSN qualified clinical representative at all times

Enrollees can utilize the toll free numbers 1-866-WE R 4 KIZ OR 1-800-523-1786 to access a language line for interpretations at no cost to the enrollee.

HealthCheck/ initial EPSDT screens shall be offered to new Enrollees within 60 days of the Enrollee’s enrollment date with HSCSN or at an earlier time if an earlier exam is needed to comply with the periodicity schedule

HealthCheck / initial screen shall be completed within three (3) months of the Enrollee’s enrollment date with Contractor, unless Contractor determines that the new Enrollee is up-to-date with the EPSDT periodicity schedule

All HealthCheck / EPSDT screens, laboratory tests, and immunizations shall take place within 20 days of their scheduled due dates for children under the age of two (2) and within 30 days of their due dates for children over the age of two (2). Periodic EPSDT screening examinations shall take place within 30 days of a request

IDEA multidisciplinary assessments for infants and toddlers at risk of disability shall be completed within 30 days of request, and any needed treatment shall begin within 15 days of the completed assessment

Enrollees have the right to second opinions if he/she refuses or disagrees with a recommended Plan of Treatment. HSCSN Medical Director must preauthorize the provider who is to render the second opinion

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D. Access Standards

SPECIALTY

VISIT TYPE ACCESS STANDARD

All Medical Specialties

Emergency Immediate, no prior authorization required.

Mental Health Providers Emergency Telephone assessment within 15 min. of request Face-to-face assessment within 90 min. of completion of the telephone assessment

PCP & Mental Health Providers

Urgent Within 24 hours of request

Specialists Urgent Within 48 hours of referral

Pregnancy/Family Planning Initial Visit Within 10 days of request

All Specialties - Routine appointments

- EPSDT - Routine referrals - Non-urgent care

Within 30 days of request

E. Contracting

HSCSN recruits licensed, Board-certified or Board eligible providers as needed, to provide comprehensive, accessible, and Culturally Competent Care. In addition to the contracting process, the practitioner will undergo credentialing. This occurs once the contract has been reviewed and signed by the prospective group. A provider is considered to be “contracted” when their contract has been executed (signed and dated by both parties). INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (DC-1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by Titles V, XVIII, XIX, AND XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the District of Columbia state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the D.C. State Agency to enter into an agreement or contract with any such institution or in termination of existing agreements. See forms section for Disclosure Form. (See Appendix A – Forms)

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Council for Affordable Quality Care (CAQH) ID All practitioners applying for participation under a group contract must obtain a CAQH ID. Practitioners should submit a Provider Interest Form via electronic mail or fax. In order to expedite the credentialing process, please be sure to update all pertinent information with CAQH. (See Appendix A – Forms) If you do not have a CAQH ID: Groups Contracted with HSCSN Prospective Contracts with HSCSN Send request to tdesta@hscsn.org or fax (202) 480-2333 Attn: Tirsit Desta

Send request to jford@hscsn.org or fax (202) 480-2333 Attn: Jackie Ford

F. Provider Credentialing Process

Initial Credentialing – Criteria, Verification and Time Limits Interested parties may apply for participation by completing an application through CAQH at https://upd.caqh.org/oas or contact the CAQH Help Desk at 1-888-599-1771. All dental providers interested in participating with HSCSN should contact the Quality Plan Administrators (QPA) at (202) 722-2744. Next Steps:

1. A pending file will be created and you will be notified of your CAQH ID. 2. Once you have obtained your CAQH ID, you will then need to login to CAQH to

complete your provider application. 3. Upon completion of your application, CAQH will send you a confirmation that they have

received your data. 4. Notify the Credentialing department (phone (202) 974-4693 or email tdesta@hscsn.org to

advise that your application has been accepted by CAQH. Your CAQH ID may be used by any health plan that is actively participating with CAQH. Completed applications will be downloaded and processed within 60 days. You have the right to be advised of your application status and may contact the Credentialing department via phone at (202) 974-4693 or in writing. Once the application process is completed, you will be notified by certified mail of the Credentialing Committee’s decision.

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Recredentialing HSCSN re-credentials its providers every three years. HSCSN will only contact you if your CAQH information is outdated. Medicaid requires that Primary Care Providers contact HSCSN, if patient panel exceeds 2,000 Medicaid-eligible patients. You must notify HSCSN at least 30 days in advance of reaching maximum capacity. Frequently Asked Questions (FAQs) About the Credentialing Process

This FAQ is provided to health care personnel and practitioners to familiarize you with HSCSN’s credentialing process and how it relates to CAQH (Council for Affordable Quality Healthcare). Please visit https://upd.caqh.org/oas to complete the credentialing application.

1. What is CAQH?

CAQH is a national organization used to collect provider data for credentialing purposes. The application may be used by any participating health plan with CAQH. This streamlines the credentialing process for practitioners by reducing paperwork.

2. What if I do not have a CAQH ID?

HSCSN will only accept CAQH applications. In order to obtain a CAQH ID, please complete the provider interest form and forward to:

Groups Contracted with HSCSN Prospective Contracts with HSCSN Send request to tdesta@hscsn.org or fax (202) 480-2333 Attn: Tirsit Desta

Send request to jford@hscsn.org or fax (202) 480-2333 Attn: Jackie Ford

Please have the following available:

a. Practitioner’s first and last name b. Address and telephone number c. Date of Birth d. Social Security Number e. Specialty

3. How long does the credentialing process take?

On average, applications are processed within 30 days.

4. What can cause a delay in the credentialing process?

When an application is not complete in CAQH, this will cause a delay in the credentialing process. Prior to informing HSCSN of your intent to become a provider, please be sure to:

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a. Review your CAQH application b. Check for expiring licensures and certificates c. Sign and date the Attestation d. Update all material as needed

5. I’ve completed my application on CAQH. Why is it not current with HSCSN?

When an application is complete on CAQH, there are several reasons HSCSN will request updates and/or additional information:

a. CAQH may not meet the specific guidelines required by HSCSN b. It takes several days for CAQH to scan documents i.e. (license, liability) Please allow 72

hours for CAQH data base updates.

6. How soon am I able to begin seeing patients?

Upon approval of your application, you will receive a certified letter informing you of the effective date.

7. Can I become credentialed before I have a contract with HSCSN?

No. A contract should be obtained prior to you being credentialed. Please contact jford@hscsn.org or (202) 495-7644 if you are interested in becoming a provider with HSCSN.

8. Who can I contact for further assistance?

Please contact Jackie Ford at jford@hscsn.org for contracting inquiries and Tirsit Desta at tdesta@hscsn.org for credentialing inquiries.

G. Customer Care

Verifying Enrollee Eligibility Providers should verify an enrollee’s plan membership and eligibility prior to providing any service except a service in response to an Emergency Medical Condition. Providers are responsible for providing immediate services for an enrollee’s Emergency Medical condition in accordance with the provider’s license and scope of practice. Verification of an enrollee’s health plan membership is not required for requests for emergency medical assistance. If you need assistance with verifying an enrollee’s eligibility please contact the Customer Care Department at (202) 467-2737 or 1-866-WE R 4 KIZ or 1-866-937-4549.

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i. Enrollment The Department of Health Care Finance which oversees DC Medicaid Managed Care provides HSCSN a list of eligible enrollees each month. The list includes demographic information including name, address, phone number, Medicaid number and date of birth. Information Collected During the Assessment Survey

- Background information - Housing environment assessment - Characteristics of the condition - Family needs - Mental health/distress - Educational and vocational information - Health Services utilization - Supplemental assessment questions - Home Care Services

A Family and Community Development Representative contacts potential enrollees (or potential enrollee caregivers) by telephone to schedule an assessment interview. If the enrollee/caregiver is inaccessible by telephone, the Outreach Representative will visit the home to schedule an appointment for an HSCSN orientation. During the orientation, the Outreach Representative will explain the program and conduct an assessment survey for those who elect membership. The Enrollment Coordinator will confirm each enrollees SSI and Medicaid eligibility and will follow up with potential enrollees/caregivers to complete the enrollment and assessment checklist. After assessments are completed, HSCSN will notify the Department of Health Care Finance of enrollees. The enrollment process is complete after the Department of Health Care Finance sends HSCSN written approval of the enrollees. New enrollees are then forwarded a welcome letter and ID card to access service at the beginning of the month.

ii. Cultural Competency Understanding Cultural Competency: Health care providers are expected to obtain cultural background information on a patient, to help them better understand the patient’s needs and apply the knowledge in the course of their care to that patient. HSCSN providers are required and expected to intimately acquaint themselves with the cultural essence of a child with special health care needs so as to assist in the management and care of the child. Assessing Cultural Competence: There are some unique indicators that have been determined for children with special health care needs. These key indicators are very important in assessing cultural competency for children with special health care needs and include:

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- Physical disability - Mental disability

- Family background

- Language

- Diet and nutrition

- Race and ethnicity

- Cultural beliefs

HSCSN takes into consideration the cultural background and behavioral pattern of the caregiver when dealing with our population. This is because the HSCSN member population consists of Pediatrics most of whom are under the care of the parents or a ward described as the caregiver. It is understood that access and delivery of quality care is as much dependent on the caregiver as much as the provider. HSCSN Providers are expected to take this into consideration. Domain areas in assessment of Cultural Competence by a health care provider, as defined in HRSA (Health Resources and Services Administration) findings are as follows*:

- Organizational Values: An organization's perspective and attitudes with respect to the worth and importance of cultural competence and its commitment to provide culturally competent care.

- Governance: The goal-setting, policy-making, and other oversight vehicles an organization uses to help ensure the delivery of culturally competent care.

- Planning and Monitoring/Evaluation: The mechanisms and processes used for: a) long- and short-term policy, programmatic, and operational cultural competence planning that is informed by external and internal consumers; and b) the systems and activities needed to proactively track and assess an organization's level of cultural competence.

- Communication: The exchange of information between the organization/providers and the clients/population, and internally among staff, in ways that promote cultural competence.

- Staff Development: An organization's efforts to ensure staff and other service providers have the requisite attitudes, knowledge and skills for delivering culturally competent services.

- Organizational Infrastructure: The organizational resources required to deliver or facilitate delivery of culturally competent services.

- Services/Interventions: An organization’s delivery or facilitation of clinical, public-health, and health related services in a culturally competent manner.

*Excerpt from Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile, www.hrsa.gov/culturalcompetence/indicators. Health care providers should strive to become culturally competent. It is essential when dealing with a dynamic patient population, such as HSCSN members under the Department of Health Care Finance.

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Five essential elements contribute to an institution’s or agency’s ability to become culturally competent. The five elements are:

- Valuing diversity - Capacity for cultural self-assessment - Conscious of the dynamics inherent when cultures interact - Institutionalized cultural knowledge - Developed adaptations of service delivery reflecting an understanding of cultural

diversity. These elements should be reflected in the structure, policy and procedures and the delivery of services by the organization. *Source: Cross, T, Bazron, B, Dennis, K, and Isaacs, M. (1989). Cultural Competence Initiatives HSCSN has strived to educate our providers on the importance of cultural competency and most importantly applying it to the management of care for children with special health care needs. Some of these initiatives include:

- Language Line: Available for use by our members and providers at no charge to interact and interpret major languages. Languages include: English, French, Spanish, Portuguese, Vietnamese, Chinese, Amharic, Arabic and Korean. The Language Line is 1-866-WE R 4 KIZ or 1-866-937-4549.

- Non discrimination letter drafted, signed by the Chief Operating Officer distributed to all

providers reminding them of their contractual obligation not to discriminate against beneficiaries of Health Services for Children with Special Needs.

External Resources on Cultural Competency

- DC Concerned Providers Coalition - US Dept. of Health and Human Services, Office of Minority Health - US Dept. of Health and Human Services, Health Resources and Services Administration - DC Department of Health, Department of Health Care Finance - National Center for Cultural Competence, Georgetown University Center for Children

and Human Development Resource Websites http://gucchd.georgetown.edu/topics/special_health_needs/index.html http://www.dhs.dc.gov http://www.hrsa.gov/culturalcompetence/indicators http://www.hscpediatriccenter.org http://www.nccccurricula.info

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Enrollee Rights & Responsibilities It is the Enrollee’s and Family’s Right to:

- Be treated in a caring, respectful, culturally-sensitive and professional manner by HSCSN staff and recognition of their dignity and right to privacy.

- Receive information about HSCSN, its services, care providers and enrollee rights and

responsibilities; and know the names and titles of all health care professionals involved in the enrollee’s care.

- Make recommendations regarding the organization’s enrollee rights and responsibilities.

- Be notified in writing whenever circumstances occur that affect your membership or

benefits 30 days prior to potential change. Methods for notifying enrollees will be mailings, enrollee newsletters and loop tape messages.

- Choose and change the child’s PCP or care manager to meet the child’s needs.

- Understand the child or youth’s health problems and consent to treatment before it is

provided.

- Understand prior authorization procedures.

- To have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.

- Be a part of the decision making process regarding the child or youth’s health care, and

the right to say yes or no to treatment before it is given to the enrollee. Enrollees have the right to seek a second opinion and/or to refuse proposed treatment.

- If an appropriately qualified provider is not available within the Network, HSCSN shall

arrange for a second opinion outside the Network at no charge to the enrollee.

- Help develop and receive a current copy of your child or youth’s plan of treatment.

- Be transported to all medically necessary appointments.

- Receive information about your child’s treatment and HSCSN’s policies in a language that allows you to understand and make decisions;

- Voice concerns, complaints, and grievances to HSCSN staff and receive a timely

response.

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- Contact the Department of Health Care Finance Ombudsman and/or receive an Administrative hearing about concerns, complaints or grievances at any time without fear of retribution, even receiving assistance from HSCSN or DC Medicaid staff if needed.

- Designate Advance Directives about your child’s care in situations where there is danger

of death, and create Advance Directives stating what you want done if you are unable to make your own medical decisions, if you are 18 years of age or older, chronologically and functionally.

- Have the child’s or youth’s medical records kept confidential and released generally only

with written permission from a parent, legal guardian, or emancipated minor.

- Be able to request and receive a copy of his or her medical records, and request that they be amended or corrected as specified in 45 C.F.R. sec. 164.524 and 164.526.

- If required by law, be notified in writing within ten (10) days, when information

concerning your child’s care has been released in response to an attorney request, subpoena and/or court order.

- Have the child or youth receive considerate health care with privacy during treatment,

interviews and any care planning meetings;

- Have access to HSCSN’s health care services for the child or youth 24 hours a day, every day of the year.

- Enrollees and/or their authorized caregivers have the right not to be subjected to

intimidation, coercion, discrimination or retaliation for any reason.

- Every newly eligible or current enrollee with limited English proficiency or no English (LEP) will receive an oral interpreter and translation service free of charge when requested.

- Have all vital documents translated in other languages available to newly eligible and

current enrollees approved by the Department of Health Care Finance.

- An enrollee with LEP has the right to file a complaint or grievance if oral and translation services are not provided in a timely manner.

- To be free from any form of restraint or seclusion used as a means of coercion, discipline,

convenience and/or retaliation.

- Have knowledge of HSCSN’s financial condition, structure and operation.

- Description of HSCSN’s prescription drug formulary, the Dispense as Written (DAW) policy and the enrollee’s right to have a prescription filled, while a prescription is being disputed under a Grievance or Appeals process.

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- A description of HSCSN’s Physician Incentive Plans (PIPs) in accordance with 42 C.F.R., Section 417.479(h)(3). DD. Summaries of any enrollee satisfaction survey in accordance with the requirements found at 42 C.F.R. sec. 438.10(i)(3)(iv).

- Receive Family Planning Services and supplies from any Medicaid provider in the

District of Columbia.

- Receive a copy of an Enrollee Handbook and a Provider Directory. It is the Enrollee’s and Family’s Responsibility to:

- Treat HSCSN staff and providers with the same courtesy and respect that you expect when receiving health care or care coordination services.

- Actively participate with the child’s providers and care managers in developing and

following plans and instructions for care that they have agreed on with their providers.

- Understand your child’s health problems and participate in developing agreed upon treatment goals to the degree possible.

- Notify the child’s care manager and PCP if you would like to make a change in the plan

of treatment.

- Have the child’s Membership Card and shot record available when receiving health care services.

- Keep all health care visits and notify the provider and HSCSN 24 hours in advance (or as

soon as possible) when appointments are cancelled.

- Be ready when scheduled transportation arrives to pick up your child for a health care visit.

- Have a grown-up (adult) with enrollees under 18 years old when going to medical office

visits. The grown-up has to stay with the enrollee during the ride to the medical appointment and while the enrollee is seeing the provider (doctor, dentist, etc.)

- Be ready to receive your child or youth when the transportation company returns your

child from a scheduled health care visit or school activity.

- Ensure there is a responsible adult available to receive the child if you are not able to be there or are detained.

- Provide HSCSN with appropriate written releases of information (ROI) when requested.

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- Notify HSCSN and Economics Security Administration (ESA) immediately about changes in name, address, telephone number, emergency contact person, when a enrollee is pregnant or has had a child while enrolled with HSCSN, death of a parent or legal guardian or enrollee, loss of SSI, placed in an institution, incarcerated, death or other information that affects our ability to contact you.

- Inform your child’s providers and care manager about the child’s medical history,

answering questions to the best of your knowledge.

- Be an active advocate for your child’s best health by informing the HSCSN care manager, the network provider and/or DC Medicaid about your complaints and grievances.

- All clinical trials and experimental medications must be pre-authorized.

- Go to the Emergency Room only if you have a medical emergency

- Help your doctor in getting medical records from providers who have treated you in the

past.

- Report to the Economics Security Administration (ESA) and HSCSN if you or a family member has other health insurance.

- Know the benefits and services available to your child or youth with special health care

needs under the HSCSN program. - Not engage in fraud or abuse in dealing with HSCSN, your primary care provider or other

providers.

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H. Care Management

Each enrollee is assigned an individual care manager at the time of enrollment. Assignment is based on the level of medical or psychiatric acuity and the complexity of care coordination required by the enrollee. Care management staff is comprised of registered nurses, social workers; licensed health care professionals and other skilled individuals with credentials, experience, education and expertise appropriate to serve the membership. The care management department maintains an on-line, integrated confidential database of enrollee information. This system has reporting capabilities that support utilization management and continuous quality improvement activities. Care Management facilitates communication and collaboration among enrollees of the care team to ultimately strengthen the PCP and the Medical Home. It also serves to empower the families of children and youth with special health care needs to be full participants in accessing necessary services and developing the enrollee’s care plan. The care manager identifies additional services, including those provided by public and private agencies that will maximize health and well-being, and makes arrangements for “enabling services,” such as transportation and respite care, to complement customary health care. Care Coordination Plan (CCP) Each enrollee receives an individualized Care Coordination Plan outlining anticipated preventive, diagnostic and treatment services. The CCP is problem-based and is adjusted for the enrollee’s age and medical issues. It is continually updated, but formally revised and approved annually. The Care Manager develops the CCP collaboratively with the enrollee/caregiver, the PCP, and other providers as appropriate. The CCP is approved, signed, and dated by the PCP and enrollee/caregiver, then returned to the care manager. The PCP must maintain copies of current and past CCP’s in the enrollee’s record. Referrals and Authorizations Care management staff is available to assist providers and enrollees with referrals and authorizations 24/7. Authorizations are provided in accordance with HSCSN policies, procedures and criteria approved by the Chief Medical Officer, a panel of physician advisors, and the HSCSN Quality Council. Authorizations are consistent with nationally recognized standards of care. HSCSN policies specify that the PCP must approve all requests made by specialists for referrals to other specialists or outpatient services, or for supplies or equipment. A Specialist making a recommendation should contact the PCP directly, or may request assistance from the care manager to seek PCP approval and make necessary arrangements. The Specialist must provide justification for all requests. Some services will require HSCSN’s Chief Medical Officer’s approval. The easiest way to make a referral is to contact the care management department at 202 467-2737. Providers may also fax or mail requests for referrals or authorizations to Care Managers. The Care Manager assigned to the enrollee will facilitate the referral and authorization process.

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Care Managers will request the following information:

- Enrollee name - Enrollee ID # and/or date of birth - Specific information on the requested services/procedures - Name of requested specialty provider (PCP may have a preference) - Reason for referral - Number of visits needed and frequency/duration of treatment - Physician orders or prescriptions - All other information that should be communicated to the PCP, specialty or ancillary

provider

I. Family and Community Development (Outreach) Services HSCSN’s Department of Family and Community Development is an essential player in the social care management program for HSCSN and is responsible for member education, engagement and targeted compliance. Outreach services are located at 2124 Martin Luther King, Jr. Avenue, SE, Washington, DC 20020. The outreach center houses a multi-purpose room for trainings and meetings, child care facilities, family support offices for support group operations, and a resource center for use by the community. The community is able to walk in and inquire about services and benefits and receive resource information. To learn more about HSCSN’s outreach services, visit www.hscsn-net.org/outreach or contact the Department at (202) 580-6485. Family Support Programs

- Male Caregivers Advocacy Support Group provides support and information specifically for male caregivers of children with special health care needs. Through this forum, participants form strong bonds and receive tools to enable them to become better caregivers and advocates for their children. MCAS has served as a national model for promoting male engagement and continuous participation by males in the caregiving process. MCAS meetings are held on a weekly basis.

- Parent Advocate Leaders Support Group is a community-based outreach program that provides peer support, advocacy training and mentoring to parents of children with special health care needs. Held on a monthly basis, PALS is a parent network that supports parents in accepting their children’s diagnosis, overcoming resource deficiencies, gaining knowledge of family rights, and coping with a lack of social support.

- Youth Athletic Program is an adaptive sports program for at-risk youth, including those with disabilities and chronic illnesses. The program is designed to engage children in physical activity, promote the importance of making healthy choices, and gain an understanding of seasonal sports such as basketball, cheerleading, T-ball, flag football, soccer and golf.

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- Healthy Living Program serves as a resource for the community to understand approaches for addressing chronic disease and promote a healthy lifestyle through wellness, nutrition and fitness classes. The program offers three free movement classes: yoga, belly dancing and jazzercise. All movement classes are held at the Family and Community Development Center and open to the community.

Clinical Support Projects

- Lead Prevention Project – Along with partner organizations, outreach representatives conduct home visits to test for lead in the homes of children with special health care needs under age 6 that have not had an initial or second lead level screening.

- Durable Medical Equipment Verification - Outreach representative conducts home visits to verify appropriate delivery, condition and education of DME.

Community Services Advisory Council - CSAC is a special advisory arm that provides advice on methods to improve health care services for children and youth that have disabilities and/or complex medical and psycho-social needs. CSAC recommends methods to improve and enhance the program’s capability to actively and proactively improve health care delivery services to children and youth with special health care needs, their families, and their communities. Strong Advocacy Program - Through our community partnerships, we have a cadre of clinicians who make presentations to our support groups about diagnoses and other special issues. Discussions are structured to educate and empower our group members, their families, and communities. Simultaneously, we provide assistance to presenters as they develop papers and projects for the disability community. Community Awareness - Community events such as health fairs, collaborative meetings, local, national, and international conferences are conducted to increase awareness of health services available to children with special health care needs. Meetings at shelters and faith-based organizations promote immunization and lead screening initiatives. Community Partnerships - The Department of Family and Community Development has established partnerships with several community organizations through its family support system. These organizations help to conduct research for measureable outcomes related to support group activity, and provide training to support group members. Some of these partners include Advocates for Justice and Education, Breathe DC, DC Department of Parks and Recreation, Georgetown University, Goodwill of Greater Washington, Lead Safe DC, Lead Safe Washington, Melwood Recreation Center, National Fatherhood Initiative, Quality Trust for Individuals with Disabilities, United Planning Organization and the University of the District of Columbia.

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J. Claims and Billing HSCSN will process all claims through an automated system. Our goal is to pay providers for covered services within 30 days of receipt of each completed clean claim form. Your tax identification number is your provider ID. Please include it and the NPI on every claim to help expedite payment. Professional providers and Home Health Agencies are required to submit for payment of covered services on the Centers for Medicare and Medicaid Services (CMS)-1500 Health Insurance Claim Form and Home Health Agencies. Hospitals are required to submit for payment of covered services on the CMS UB04. These forms are available from CMS at http://www.cms.hhs.gov/CMSForms. Providers have the option of submitting claims electronically through EMDEON or via mail. HSCSN’s payor ID is 37290. Claims should be mailed to: HSCSN P.O. Box 29055 Washington, DC 20017 Do not submit a duplicate claim for at least 45 days after submitting the original claim. As a provider for DC Medicaid, HSCSN is always payer of last resort. If the enrollee has other insurance coverage, submit to the other carrier first. HSCSN will only consider the claim after it is submitted with an Explanation of Benefits from the other carrier or with a letter of denial. Electronic Submission of Claims HSCSN is able to accept claims electronically that are processed through EMDEON clearinghouse. It is not necessary that you use EMDEON—only that your claims management company is able to submit claims through EMDEON as a clearinghouse. If you have any questions, contact your claims management provider. To submit claims, you will need the HSCSN Payor ID which is: 37290. Advantage of Electronic Claims Submission

- Claims can be tracked electronically at www.emdeon.com/PayerLists/payerlists.php - Improved patient collections - Rapid and accurate payment processing

If you are currently not submitting electronically and have an interest in doing so, please let us know. HSCSN’s payor ID for electronic submission is 37290 and Emdeon is the clearinghouse that we use.

Claim

s and Billing

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Claims Payment Capacity HSCSN shall pay all claims for Covered Services provided to Enrollees on dates of service when they were eligible for enrollment. HSCSN has written policies and procedures for processing claims submitted for payment from any source and monitors compliance with those procedures. The procedures, at a minimum, specify time frames for:

- Submission of Claims - Date stamping Claims when received

- Determining, within 30 days from receipt, whether a Claim is a Clean Claim

- Payment of Claim in accordance with the Prompt Payment Act, D.C. Code §31-3132

- Follow-up of pending and denied Claims to obtain additional information

- Reaching a determination following receipt of additional information

- Payment of Claims following receipt of additional information

- Sending notice of a denied Claim to the Enrollee and the Provider, which includes

Appeal rights and how to access the Fair Hearing process.

- HSCSN shall utilize the standard Denial of Claim form provided by the Department of Health Care Finance

Timely Processing of Claims

- In accordance with D.C. Code § 31-3132, HSCSN shall accept Network and non-Network Provider initial Claims for Covered Services no later than one hundred and eighty (180) days from the date of service.

- HSCSN will pay ninety percent (90%) of all Clean Claims within 30 days of receipt

consistent with the claims payment procedures described in Section 1902(a)(37)(A) of the Social Security Act and 42 C.F.R.§§ 447.45.

In-Patient Authorizations HSCSN has a Utilization Review Mailbox. Hospital providers are required to provide the following information within 24 hours of admitting an enrollee:

- Patient name, date of birth - Room number (if applicable)

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- Diagnosis (if known,) - Date/time of admission

Hospital providers are requested to call the Utilization Review mailbox at (202) 721-7162 with the aforementioned information. For more information, please contact the HSCSN Customer Care Department at (202) 467-2737. International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) ICD-9-CM was sponsored in 1979 as the official system for assigning codes to diagnoses (inpatient and outpatient care, including physician offices) and procedures (inpatient care). The ICD-9-CM is available from commercial publishing companies and are helpful in manual coding because they contain color-coded entries that identify required additional digits, nonspecific and unacceptable principal diagnoses. International Classification of Diseases 10th Clinical Modification (ICD-10-CM) Effective October 1, 2013, ICD-10-CM codes will be required. The biggest difference is that the new ICD-10 codes are alphanumeric. ICD-10-CM far exceeds ICD-9-CM in the number of codes provided, having been expanded to 1) include health-related conditions, 2) provide much greater specificity at the sixth digit level, and 3) add a seventh digit extension (in some conditions). Assigning the sixth and seventh characters when available for ICD-10-CM is mandatory because they report information documented in the patient records. Current Procedural Terminology (CPT®) Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying 5-digit codes for reporting medical services and procedures. Procedures and services submitted must be linked to the ICD-9-CM code that justifies the need for the service or procedure. Modifiers The CPT® coding system includes two-digit modifiers that are used to report that a service or procedure has been “altered or modified by some specific circumstance” without altering or modifying the basic definition or CPT code. The proper use of CPT modifiers can speed up claim processing and increase reimbursement, while improper use of CPT modifiers may result in claim delays or claim denials. 1 Healthcare Common Procedure Coding System (HCPCS) Healthcare Common Procedure Coding System and is used to describe durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and certain other services reported on claims. 1 CPT PLUS! 2011

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i. CMS 1500 The insurance claim used to report professional and technical services is known as the CMS-1500 claim. (See page 40 for complete instructions on the CMS1500.)

The National Uniform Claim Committee (NUCC) is responsible for the design and maintenance of the CMS-1500 form. Neither CMS nor HSCSN supplies the forms to providers for claims submission.

In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, or contact local printing companies in your area and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc.).

The only acceptable claim forms are those printed in Flint OCR Red, J6983 (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers.

Place of Service Codes

01 Pharmacy 03 School 04 Homeless Shelter 05 Indian Health Services Freestanding Facility 06 Indian Health Services Provider-based Facility 07 Tribal 638 Freestanding Facility 08 Tribal 638 Provider- based Facility 09 Prison Correctional Facility 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 16 Temporary Lodging 18 Residential Facility 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center 25 Birthing Center

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26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance land 42 Ambulance – air or water 49 Independent Clinic 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Facility – Partial Hospitalization 53 Community Mental Health Center 54 Intermediate Care Facility- Mentally retarded 55 Residential Substance Abuse treatment facility 56 Psychiatric Residential Treatment Center 57 Nonresidential Substance Abuse Facility 60 Mass Immunization Center 61 Comprehensive Inpatient Rehab Facility 62 Comprehensive Outpatient Rehab Facility 65 End-stage Renal disease treatment facility 71 Public Health Clinic 72 Rural Health Clinic 81 Independent Lab

99 Other place of service National Provider Identifier (NPI) A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique provider identification number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial health care insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA covered entities such as providers completing electronic transactions, health care clearinghouses, and large health plans were required by regulation to use only the NPI to identify covered health care providers by May 23, 2007. All individual HIPAA covered health care providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapists, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider’s NPI is permanent and remains with the provider regardless of job or location changes.

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The NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) at https://nppes.cms.hhs.gov/NPPES/Welcome.do. NPI and the CMS-1500 Block – 24J – Enter the 10 digit NPI for the provider who performed the service.

Block 33a – Enter the 10 digit NPI for billing provider or group practice/clinic.

Block 31 – Enter the name and credentials of the provider rendering the service. Any claims submitted without the NPI will be denied. ii. UB-04

The UB-04 must be completed by hospital, long-term care, hospice and dialysis providers billing for patient services. (See page 45 – complete instructions on the UB-04.) Coordination of Benefits

Health Services for Children with Special Needs, Inc. (HSCSN), is always the payer of last resort when the enrollee has another insurance coverage. As a provider, you must always submit your claims to the other insurance company first. Once you receive an explanation of payment from them, you should file the claim with HSCSN. You must attach a copy of the explanation of payment from the other carrier or a copy of the letter of denial. HSCSN will coordinate the payment with the other carrier’s payment. HSCSN will pay up to the amount that is contracted. The provider will not receive payment for more than the charge or contracted amount when combining the payments of both payers.

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EPSDT BILLING Office Visit Codes The following office visit codes are used to bill for EPSDT visits and are age specific. There are also different codes to distinguish between new and established patients.

When billing for an EPSDT visit and a sick visit for either new or established patient, use modifier 25 with the office (sick) visit.

For example: 99384 and 99201 with a modifier 25 or 99212 with modifier 25. New Patient

Established Patient These codes include the reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate laboratory and diagnostic procedures for an established patient.

Immunization Codes HSCSN pays for the administration of vaccines only. Codes for administration 90465-90474 Codes for vaccine rejected 90476-90749

Code 99381 Infant under 1 year of age 99382 Early Childhood – age 1 to 4 years 99383 Late Childhood – age 5 to 11 years 99384 Adolescent – age 12 to 17 years 99385 Age 18 to 22 years

Code 99391 Infant under 1 year of age 99392 Early Childhood – age 1 to 4 years 99393 Late Childhood – age 5 to 11 years 99394 Adolescent – age 12 to 17 years 99395 Age 18 to 22 years

Code 90700 Diphtheria, Tetanus Toxoids and Acellular Pertussis vaccine (DTap) 90701 Diphtheria, Tetanus Toxoids and Pertussis vaccine (DTP) 90702 Diphtheria and Tetanus Toxoids 90703 Tetanus Toxoid 90707 Measles, Mumps and Rubella virus vaccine, live (MMR) 90712 Poliovirus vaccine, live, oral (any type) 90716 Varicella (chicken pox) vaccine 90718 Tetanus and Diphtheria Toxoids absorbed, for adult use (Td) 90720 Diphtheria, Tetanus Toxoids and Pertussis (DTP) and Hemophilus Infuluenza B (HIB) vaccine 90744 Immunization, active, Hepatitis B vaccine; newborn to 11 years

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Labs and Screens

Dental

Health Care Acquired Conditions The Patient Protection and Affordable Care Act of 2010 include provisions prohibiting Federal Financial Participation (FFP) to States for payments for health care acquired conditions (HCACs) and other provider preventable conditions or Never Events. HSCSN shall no longer reimburse providers for procedures relating to the following health care acquired conditions when any of the following conditions are not present upon admission in any inpatient setting, but subsequently acquired in that setting. These conditions include the following:

1. Foreign Object Retained After Surgery 2. Air Embolism 3. Blood Incompatibility 4. Stage III and IV Pressure Ulcers 5. Falls and Trauma

o Fractures o Dislocations o Intracranial Injuries o Crushing Injuries o Burns o Electric Shock

6. Manifestations of Poor Glycemic Control o Diabetic Ketoacidosis o Nonketotic Hyperosmolar Coma o Hypoglycemic Coma o Secondary Diabetes with Ketoacidosis o Secondary Diabetes with Hyperosmolarity

Code 85013 85014 85018

Hemoglobin

83655 Lead screen 81000 Urinalysis 86580 86585

TB Test

83718 83719

Cholesterol

85660 Sickle Cell

Code 00120

Basic EPSDT Exam

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7. Catheter-Associated Urinary Tract Infection (UTI) 8. Vascular Catheter-Associated Infection 9. Surgical Site Infection Following:

o Coronary Artery Bypass Graft (CABG) - Mediastinitis o Bariatric Surgery

o Laparoscopic Gastric Bypass o Gastroenterostomy o Laparoscopic Gastric Restrictive Surgery

o Orthopedic Procedures o Spine o Neck o Shoulder o Elbow

10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) o Total Knee Replacement o Hip Replacement

Exempt Hospitals The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision:

Critical Access Hospitals (CAHs), Long-Term Care Hospitals (LTCHs) Maryland Waiver Hospitals Cancer Hospitals Children’s Inpatient Facilities Rural Health Clinics Federally Qualified Health Centers (FQHCs) Religious Non-Medical Health Care Institutions Inpatient Psychiatric Hospitals Inpatient Rehabilitation Facilities (IRFs) Veterans Administration/Department of Defense Hospitals

Present on Admission (POA) Indicator and the Effect on Payment

Present on admission indicator

Indicator Description Effect on payment

Y Diagnosis was present at the time of inpatient admission

HSCSN will pay for those selected HACs that are coded as “Y” for the POA Indicator

N Diagnosis was not present at time of inpatient admission

HSCSN will not pay for those selected HACs that are coded as “N” for the POA Indicator

U Documentation insufficient to determine if the condition was present at the time of inpatient admission

HSCSN will not pay for those selected HACs that are coded as “U” for the POA Indicator

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W Provider unable to clinically determine whether the condition was present at the time of inpatient admission

HSCSN will pay for those selected HACs that are coded as “W” for the POA Indicator

I Unreported /Not used. Exempt from POA reporting. (This code is equivalent to a blank on the UB-04, however, it was determined that blanks are undesirable when submitting this data via an electronic claim).

Does not affect payment. All POA indicator options coded as “1” are exempt from the HAC payment provision

Additionally, providers should not be reimbursed for any of the following Never Events in any inpatient or outpatient setting:

1) Surgery performed on the wrong body part - HCPCS Modifier - PA 2) Surgery performed on the wrong patient and – HCPCS Modifier - PB 3) Wrong surgical procedure performed on a patient – HCPCS Modifier - PC

Provider Voucher Listing HSCSN generates checks once a week and uses an outside vendor to print and mail checks. As a result, it is not possible to pick up checks from the health plan. It is imperative that you read your voucher, post your payments and review the reason code description in a timely manner. Failure to do so could result in lost revenue and worse yet, claims denied for timely filing. You have 90 days from the date on the voucher to appeal claims and/or resubmit claims with required documentation. How to read the voucher:

1. Provider’s name and mailing address 2. The voucher number 3. Check date 4. Dates of service 5. Procedure code 6. Total charge 7. Ineligible amount 8. Patient number and Claim number 9. Patient’s name and Member ID (Medicaid number) 10. Reason code description 11. Statement totals

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Balance Billing

All members of Health Services for Children with Special Needs, Inc. are Medicaid members and cannot be billed for balances over HSCSN’s paid amount. When accepting our members as patients, you agree to accept our payment as payment in full. Appeals

Claim payments or denials can be appealed in writing within 90 days of the denial or payment.

• Appeals disputing the payment amount should include a letter requesting an adjustment of payment and the reason the payment is not correct. If the reason for incorrect payment is due to a Single Case Agreement, please include a copy of that document.

• Appeals of denied claims that include, but are not limited to, late filing or services not authorized must include the documentation that supports your case for reconsideration. This may involve sending medical records or proof of timely submission.

Examples of appeals are: • Claim was denied because it was filed with HSCSN after the 180 day limit – The original

claim was filed on time with DC Medicaid. A letter requesting reconsideration should be sent along with a copy of the rejection from DC Medicaid showing they had received it timely but rejected it because it was an HSCSN member.

• Payment amount was less than expected because of a Single Case Agreement. – A letter stating the issue should be sent along with a copy of the Single Case stating the correct payment.

• Claim was denied as not authorized – A letter stating the issue should be sent along with a copy of the authorization.

• Claims was denied for medical records, nursing notes, manufacturers invoice, or any other documentation- this information must also be supplied within 90 days.

Appeals should be sent to:

HSCSN Appeals P.O. Box 29055

Washington, DC 20017

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Claims Tips Coding Services on the same date of service Help us to process your claims quicker and more accurately! Do you do multiple shifts on the same day or make multiple trips to transport one of our members? If your answer is yes and you bill the services on separate claim forms for the same member, your claim may appear to be a duplicate submission and may be delayed for further investigation or may even be denied incorrectly as a duplicate. Please help us out and help us to expedite your claims by billing all services for the same date on the same claim form. If the code is the same, you can put the services on the same claim line and indicate the number of units in box 24G of the CMS 1500. Multiple claims submissions for the same date require us to void the original claim and to reprocess your total claim all over again, extending the time to get your claim paid. Making this change will help us all to get payments out faster Do submit claims electronically Handwritten and Xerox claims will be rejected. Please submit the current version of CMS 1500 and UB-04 claim form electronically. EMDEON is our clearinghouse provider. Do give complete information on the member Please provide complete information for items such as the name, birth date, and sex. Verify that this information matches the patient’s insurance card. Watch out for name variations and changes. Errors and omissions of these items cause an unnecessary delay in processing the claim. Do give complete information on you, the provider Please provide complete information regarding the provider, including the names of both the treating provider and the billing entity. The taxpayer identification number for the billing entity must be given for the claim to be processed correctly. The billing or remittance address must be accurate for the check and/or voucher to be sent to the correct party. Do ensure that the claim form is signed by the treating provider It is important that the treating provider signs the claim form to verify that the services performed by the provider are accurately reflected in the services reported. The provider is legally responsible for the contents of the claim once the claim form is signed. Do not give a signed claims form to the member to complete. Do include the complete diagnosis If the patient has more than one Axis I diagnosis, please be sure to report all diagnoses on the claim. The diagnosis must match your authorization and the Revenue Codes (for facilities), CDT-2 (dental services) or CPT codes (for professional services) or HCPCS (for ancillary services). Include all required 4th and 5th digits. Do list each date of service for each procedure code We cannot accept dates of service combined together under “from” and “through” dates. Each date of service must be shown separately. It is permissible to use “from” and “through” date fields for consecutive dates, such as: FROM THROUGH #DAYS/UNITS 9/1/04 9/2/04

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By doing so, we are able to see each date of service. Any more than two service dates on one line will delay processing. Don’t use invalid procedure or diagnosis codes Only use current code sets (CPT, HCPCS, Revenue, and ICD-9) and select the code and diagnosis that most accurately describe the service provided. Codes other than CPT, revenue and HCPCS are generally not accepted in HSCSN’s claims processing systems. The claims may not be altered by the claims examiner; therefore, an incorrect code may result in denial of your claim. Don’t omit information on the claim because you have already provided it on the encounter/treatment plan. For confidentiality purposes, claims examiners do not have access to member encounters/treatment plans; therefore, it is necessary for you to give information on the claim that you may have already provided on the treatment plan. To assist with prompt claims processing, please be sure to provide all information required on the claim form. Do not submit encounters/treatment plans with claim forms. Treatment plans are to be mailed to the Care Management Department that authorized the services. Don’t use code 760-779.9 for children over 11 months. ICD9 Diagnosis codes 760-779.9 are only for infants up to 11 months. Top 10 Reasons Claims are Denied

1. Duplicate claim 2. Timely filing 3. Invalid diagnosis 4. Invalid age 5. Invalid sex 6. Non covered procedure 7. Bilateral procedure 8. Exceeds authorization 9. Not authorized 10. Medical records requested

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Frequently Asked Claims Questions 1. Where do we send our claims for payment? HSCSN Claims P.O. Box 29055 Washington, DC 20017 2. How do I appeal a claim that has been denied or that I think has been paid incorrectly? Send a letter of appeal and all documentation to the address above, attention: Donna Hawkins. Please be sure that you explain why the rejection or payment should be reversed. Include any documentation to support your request. If a claim was incorrectly sent to DC Medicaid and now we are denying it for late filing, please include a copy of the letter from DC Medicaid. 3. Where do I call for claim’s status? Please call our Customer Care Department at (202) 467-2737 to obtain the status of a claim. We ask that you wait 45 days from the date that you mail the claims to give the check time to get to you and for you to post the payments. More than three (3) claim status checks should be faxed to the Customer Care Department at (202) 721-7169. 4. Can I bill the member? No, all of our members are Medicaid recipients and cannot be billed. Denials and balances should be appealed to HSCSN. 5. Do I need to include my NPI number on the claim? Yes, NPI’s should be on each claim. If you do not include your NPI, you claim will be denied. 6. How long do I have to submit a claim? Claims must be received within 180 days from the date of service. 7. When can I expect payment on claims? HSCSN processes claims as they receive them and our goal is to process all claims within 30 days of the date we receive the claim. If your claims is not processed within 30 days and the claim was clean (it had all the needed information), we will pay you interest on the claim. 8. What diagnoses should be indicated on the claim? The diagnoses on the claim should be the treating diagnoses. Please be sure that the diagnosis is age and sex appropriate and contains the required number of digits. All treating diagnosis should be indicated.

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9. What procedure codes should be used? All procedure codes must reflect the services being rendered and they must be current HIPAA compliant codes. 10. Where do I call if I have a question about my contract? Please call the Contracting Department at (202) 495-7644 and someone will assist you. 11. Does HSCSN accept electronic claims? Yes. If you are interested in submitting claims electronically, HSCSN’s payor ID for electronic submission is 37290 and Emdeon is the clearinghouse that we use.

Claims Status Inquiry and Direct Claims Entry

HSCSN provider portal is a Web-based solution that simplifies the everyday tasks of physician practices by integrating claim status inquiry transactions. Providers may login to the secure portal for claim status inquiries or electronic claim submission that is another added feature.

1. Click on HSCSN Claims Status link and you will be directed to the portal login page.

2. For instructions click here HSCSN Provider Portal Self-Enrollment Process Instructions.

• For online help use the Online Support tool to create a trouble ticket. Alternatively, you

can call our toll-free customer support number at 877-667-1512.

This feature provides you with

• Secure, personalized web portal access

• Enables electronic claim inquiries from providers

• Fast implementation

• Real-time provider enrollment offering immediate electronic capability

Direct Claims Entry

This additional feature provides you with

• Direct claims entry system at no cost to the provider

• Once registered, provider may check the claim status via their Emdeon account

• Electronic Claims Tracking

• Improved patient collections

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• Rapid and accurate payment processing

• Increased efficiency of the clinical encounter

Note: If you are currently using a practice management system that provides you the ability to

submit claims electronically to Emdeon, please continue to utilize that service, as the HSCSN

portal is not intended to replace your electronic claims process. If you are not sure if your current

system has this feature, you may want to contact your practice management system vendor

directly. HSCSN Emdeon payer id for electronic claims is 37290.

HSCSN pledges to provide accurate and efficient claims processing. To make this possible, we

ask that providers submit claims promptly and to include all required information.

• HSCSN will process all claims through an automated system.

• HSCSN’s goal is to pay providers for covered services within 30 days of receipt of each

completed clean claim form.

• HSCSN requires your Tax identification number, which is also your provider ID.

• HSCSN requires your NPI on every claim to help expedite payment.

If you are unable to access the Internet, you may call our Customer Care Department at (202) 467-2737 to check the status of a claim. If you have more than three (3) claims to check, please fax your request to (202) 721-7169. Please include the enrollee’s name, Medicaid number, date of service, the amount billed, the Provider’s name, and a contact name and number. Customer Care will check your claim and respond within 48 hours.

IMPORTANT BILLING NOTICE TO HSCSN PROVIDERS WHO SERVICE

OUR OVER 18 YEARS OF AGE MEMBERS To be eligible for enrollment with HSCSN, children and young people must be under 26 years of age and must receive Supplemental Security Income (SSI) disability benefits. Providers who service the entire age range of the HSCSN membership should use the appropriate adult billing codes once the member reaches the age of 18 years. The pediatric codes are no longer valid. This billing error will delay the processing of your claim.

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Medical Consent by an Adult Caregiver A parent, legal guardian, or legal custodian may authorize an adult person, in whose care a minor has been entrusted, to consent to any medical, surgical, dental, developmental screening and/or mental health examination or treatment, including immunization, to be rendered to the minor under the supervision or upon the advice of a physician, nurse, dentist or mental health professional licensed to practice in the District of Columbia, provided there is no prior order of any court in any jurisdiction currently in effect which would prohibit the parent, leg al guardian, or legal custodian from exercising the power that they see k to convey to another person. Medical, surgical and dental treatment or examination may include any x-ray or anesthetic required for diagnosis or treatment. Any written form that is signed by the parent, legal guardian, or legal custodian may be used to convey this authority. Any written statement signed by a parent, legal guardian, or legal custodian is governed by the laws of forgery in the District of Columbia. A conveyance of authority shall be honored by any health care facility or practitioner. The existence o f a written document conveying the authority described above creates a presumption that their authority has been lawfully conveyed. The conveyance of authority described is revocable at will, unless other terms are agreed to by the parent, legal guardian, or legal custodian and the person to whom authority is being conveyed. The parties may provide for terms in writing which would require the revocation of authority to be in writing, make r evocation effective only when a specified time period has elapsed after notification of intent to revoke, or any other terms that the parties deem appropriate. A physician, surgeon, nurse, mental health professional, dentist, or other health care professional, or a hospital or medical facility, that relies on a written instrument which authorizes another adult to consent to medical treatment of the executor’s minor child or ward shall not incur civil liability for treating a minor without legal consent if a reasonable and prudent health care professional would have relied on the written instrument under the same or similar circumstances. Out-Area Covered Services HSCSN follows procedures to identify appropriate providers and coordinate needed services that will be rendered outside the local (District of Columbia) area. Authorization will be generated, upon approval from the Chief Medical Officer.

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II. Enrollee Benefits and Authorizations

A. Benefits and Pharmacy List The list below shows the health care services and benefits for all HSCSN enrollees. For some benefits, you have to be a certain age or have a certain need for the service. HSCSN will not charge you for any of the health care services in this list if you go to an In-Network provider or hospital. HSCSN does not pay for a service or treatment that:

1. Is not medically necessary 2. Is not described in the list of covered benefits 3. Is investigational, experimental or part of a clinical trial 4. Is of an amount, duration or scope in excess of a limit expressly set by the DC

Department of Health Care Finance 5. Transportation services to or from covered services furnished in other than educational

settings, when the transportation is furnished by DCPS or DCPS contractor. 6. Services furnished in a school setting by DCPS employees or school contractors or, if

Enrollee resides in a private school. If you have a question about whether HSCSN covers certain health care, call Customer Care Services at (202) 467-2737.

Enrollee B

enefits and Authorizations

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BENEFIT SERVICES COVERED

Primary Care Services Preventive, acute, and chronic health care

services generally provided by a primary care provider (PCP)

Specialist Services

Health care services provided by specially trained doctors or advance practice nurses.

Does not include cosmetic services or surgeries

except when surgery is required to:

o correct a condition resulting from surgery or disease

o correct a condition created by an accidental injury

o correct a congenital deformity o correct a condition that impairs the

normal function of a part of the body

Laboratory & Radiology Services Lab tests and X-rays

Hospital Services

Outpatient Services (preventive, diagnostic, therapeutic, rehabilitative, or palliative)

Inpatient Services (hospital stay)

Pharmacy Services

Prescription medications must be obtained from network pharmacies

The following over-the-counter medicines are

covered when prescribed by a physician: - Acetaminophen & Combinations - Antacids - Broncho Saline 0.9% Aerosol Spray - Cotton Balls - Condoms - Contraceptive Creams/ Jellies, Foams,

Diaphragms, Kits & Cervical Caps - Enteral Nutritional Supplements - Ferrous Sulfate - Mineral & Nutrient Supplements - Non-Narcotic Analgesics - Analgesics - Allergy Medications - Prenatal Multivitamins - Pediatric Multivitamins - Salicylates - Aspirin & Combinations - Senna, Sennosides - Sodium Chloride - Smoking cessation products

Peak flow meters and spacers for asthma are covered

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BENEFIT SERVICES COVERED

Pharmacy Services

Prior authorization is required for:

- Duloxetine (Cymbalta) for individuals through age 17

- Synagis - Growth Hormones - Hemophilia medications - Smoking cessation drugs for individuals

through age 17 - Estrogens and progesterones for males - Androgens for females

Pharmacy coverage does not include: - Anti-obesity drugs - Nefazodone (Serzone) - Infertility drugs - Drugs intended primarily for cosmetic purposes

including anti-wrinkle agents, hair removers, hair growth stimulants

- Immunization agents - Therapeutic devices or appliances unless listed as

a covered product - Over-the-counter (OTC) products except where

specifically listed as covered - Prescription drugs for an Enrollee who is dually

eligible for Medicare and Medicaid; exceptions include benzopdiazepines, barbiturates and covered over-the-counter medications.

Emergency Services

A Screening exam, treatment and stabilization of an emergency health condition regardless of whether the Provider is in the HSCSN network

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BENEFIT SERVICES COVERED

Family Planning & Pregnancy-Related Services

Routine examinations to determine overall reproductive health

Pregnancy testing and counseling (for female and couple)

Routine and emergency contraception Screening, counseling and immunizations

(including for HPV and Hepatitis B) Screening and treatment for all sexually

transmitted diseases Voluntary sterilization procedures (tubal ligation

and vasectomy only) for Enrollee over 21 years of age (requires signature of an approved sterilization form by the Enrollee 30 days prior to the procedure)

Pregnancy care, including all related testing Routine and high risk obstetrical services Post partum care

Family planning services do not include:

Abortions Infertility studies or procedures Sterilization procedures for Members under age

21 Hysterectomy for sterilization Reversal of voluntary sterilization

Preventive Health Services

Immunizations Screening for obesity Diet and behavioral counseling Diabetes screening and referral Screening for renal kidney disease Tobacco cessation counseling Substance abuse screening and behavioral

counseling Screening and referral for depression HIV/AIDS screening, testing, and counseling Women’s wellness, consisting of an annual

gynecology examination Routine pelvic exam, including Pap smear Screening and immunization for Human

Papilloma Virus (HPV) Screening and counseling for sexually transmitted

infections/diseases

Podiatry Special care for foot problems

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BENEFIT SERVICES COVERED

Rehabilitation Services Includes physical, speech and language, occupational and vision therapies

Prosthetic devices Corrective, supportive and replacement devices

prescribed by a licensed provider (includes orthotics and prosthetics)

Vision Care

Eye exams at least once every year and as needed Eye glasses (corrective lenses) limited to one (1)

complete pair in a twelve (12) month period, except when Enrollee has lost eyeglasses or when the prescription has changed more than one-half (0.5) diopter

Contact lenses, when medically necessary, and unable to wear eye glasses

Care Coordination

Assistance to Enrollees who need or are receiving:

- Community-based intervention (CBI) - Multi-systemic therapy (MST) - Assertive Community Treatment (ACT) - Rehabilitation Option Services

Home Health Services

Services provided by a home health agency, including:

- Skilled Nursing - Home health aide and personal care aide - Physical, occupational and speech

therapy - Licensed clinical social work

Home Modification

Home modification for Enrollees whose home requires medically necessary equipment, personnel, or structural change for safety of the enrollee

Caregiver must own the home

Respite Services

Respite services for families with responsibility for maintaining a demanding treatment and monitoring regime for a child with a catastrophic medical or behavioral condition

Long-term Care and Intermediate Care Facility (ICF) Services

Long-term care services for Enrollees residing in a skilled nursing facility, rehabilitation hospital or ICF for Mental Retardation/Intellectual Disability

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BENEFIT SERVICES COVERED

Hospice Care Support Services for end of life care

Transportation Services

Health care-related transportation services unless transportation is provided by the school system

Adult Wellness Services (Enrollees age 21 and older)

Routine screening for Sexually Transmitted Diseases

HIV/AIDS screening, testing and counseling Breast cancer screening Cervical cancer screening HPV screening Prostate cancer screening Abdominal aortic aneurysm Screening for obesity Diabetes screening Screening for high blood pressure and cholesterol Screening for depression Smoking cessation counseling Diet and exercise counseling Alcohol and drug screening

EPSDT Services (Members under age 21)

Preventive screening, assessment and treatment services for 0- 21 years, including but not limited to:

- Health and developmental history and screenings

- Mental health and developmental history and Screenings

- Comprehensive health exam - Immunizations - Lab tests, including blood lead levels - Health education

Dental Screening, diagnostic and treatment services

Vision Screening, diagnostic and treatment services

Hearing Screening, diagnostic and treatment services

Alcohol and drug screening, diagnostic and treatment services

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BENEFIT SERVICES COVERED

Dental Benefits

General dentistry (including regular and emergency treatment)

Check-ups twice a year with a dentist for ages 12 months through 20 years

A PCP can perform dental screenings for a child up to age 3

Orthodontic care for members through age 20

Hearing Benefits Diagnosis and Treatment of conditions related to

hearing, including exams, testing, hearing aids and hearing aid batteries

Mental Health Services

Services furnished by mental health care Providers, including:

- Diagnostic and Assessment services - Individual, group and family psychotherapy - Crisis services, including emergency

department - Partial hospitalization - Inpatient hospitalization - Intensive outpatient services - Case management services - Psychiatric Residential treatment facility

services (enrollees under age 21)

Substance Abuse Services

Inpatient drug and alcohol detoxification and treatment

Outpatient drug and alcohol treatment

Communicable Disease and Public Health Services

Includes, but is not limited to: HIV and AIDS diagnosis and treatment

services Tuberculosis-related services

Respiratory Therapy

The assessment and treatment of lung disease or condition when part of a treatment plan developed by a physician or advance practice nurse

Services provided on a part-time basis in the Enrollee’s home by a respiratory therapist or other health care professional trained in respiratory therapy

Durable Medical Equipment (DME), Assistive Technologies & Disposable Medical Supplies (DMS)

Medically necessary equipment, supplies and augmentative communication devices

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Prescription Drugs and Medicare Part D HSCSN covers all medications on the Department of Health Care Finance Formulary, including their generic and therapeutic equivalents. Where there is a generic equivalent the pharmacy will only provide the generic unless the provider has written the prescription to be “dispensed as written.” Some enrollees are eligible for the Medicare Part D program. DC Health Care Finance enrollees that have dual eligibility for Medicare will have most of their drug coverage under a Medicare Part D Prescription Drug Plan (PDP). Dual eligibility enrollees have most of their prescription drugs covered under a Prescription Drug Plan. Individuals who do not chose a PDP will be automatically enrolled in one. Medicare Part D may have a charge; however, enrollees can receive assistance to pay for premiums. In addition, a cost for each prescription may be required; this cost is incurred by the enrollee. The cost which may be $1.00 - $3.00 per prescription must be paid by the enrollee. Neither HSCSN nor Medicaid will absorb the cost. Information providers should share with enrollees regarding Medicare Part D

- If an enrollee has not selected a pharmacy plan (PDP) they will be auto enrolled

- Enrollees automatically enrolled can change their Pharmacy D Plan at any time

- HSCSN will coordinate with the enrollee’s prescribing practitioner to ensure enrollee has a 30 to 60 day supply of medications to cover the transition period

- Enrollees can contact the Customer Care Department at (202) 466-8383) to speak with their Care Manager

- Enrollees can learn more about the Medicare Part D Plan by telephoning 1-800-MEDICARE or 1-800-633-4227. To speak to a counselor, call (202) 739-0668. The counselor can assist with choosing a drug plan.

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B. Overview of Care Coordination HSCSN is a DC Medicaid health plan specializing in care coordination services for SSI eligible Medicaid recipients in the District of Columbia between birth and 26 years of age. The goals of the care coordination program are to ensure enrollees receive high quality health care, are knowledgeable of HSCSN benefits and resources, and work effectively with providers and agencies to improve and/or maintain enrollee health and well being. Care coordination is a series of activities provided by HSCSN Care Managers to assist enrollees in gaining access to necessary services (medical, behavioral and others), coordinate preventative and specialty services and facilitate communication and coordination in the medical home. Care coordination is individualized, empowering, comprehensive, and outcome-focused. Note: HSCSN is not a social services agency nor does its staff provide clinical services. HSCSN Care Managers cannot function as a surrogate parent/guardian or decision maker for the enrollee or caregiver. What are the Care Manager’s role and responsibilities? • Develop a relationship with and support the enrollee and/or caregiver • Develop relationships with physicians and providers servicing enrollees • Communicate with enrollee, caregiver, treating physician(s) and providers • Assist the family with identifying their medical needs • Facilitate access and coordinating services for the enrollee (identify provider, schedule

appointments, coordinate transportation) • Develop and monitor the care coordination plan • Educate enrollees and families on HSCSN benefits, resources and processes • Identify and coordinate enrollee/caregiver education needs (classes, literature, referrals) • Support the relationship between the enrollee and their providers • Connect the enrollee/caregiver with resources • Make referrals to educational advocates and attend educational meetings (with permission of

enrollee/caregiver) • Assist the provider with obtaining home evaluations and/or social work assessments • Assist the provider and family to address overutilization and underutilization of services and

noncompliance

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What are the functions of the Care Manager in care coordination? Activity Care Manager Assessments - Initial and periodic

• Perform structured interview with enrollee and/or caregiver to assess medical, physical, functional, psychosocial, behavioral, environmental, legal, vocational and educational needs and concerns

• Incorporate assessment findings in a CCP; use to help determine acuity level and frequency Care Manager interventions

Care Coordination Plan (CCP) - Initial and periodic

• To develop a summary and plan of the enrollee’s needs, strengths, goals, resources and needed actions

• Obtain Provider and Family input and signature Appointment and Referral Support

• Assisting the family with identifying providers • Scheduling/assisting with the scheduling of appointments and

transportation • Coordinating the delivery of services to reduce fragmentation of care • Facilitating communication and collaboration among all service

providers and the enrollee • Making referrals and facilitating access to community based support

services and programs • Assisting the enrollee as he/she transitions through levels of care

Preventive and Chronic Care Monitoring/ Follow-up

• Monitor compliance with all PCP and specialty appointments • Monitor ER visits and hospitalizations and follow-up • Monitor EPSDT and immunization compliance • Monitor services being provided and progress toward goal in

accordance with the CCP • Monitor for changes in the needs or health status • Conduct Face to Face visits as per acuity level

Coordination of transitions

• Participate with DCPS to coordinate Early intervention and school-based services (IFSP and IEP)

• Identify enrollees meeting the requirements for Developmental Disabilities Administration (DDA) programs, assist families with the application process, and coordinate medical services covered by HSCSN

• Discharge from hospital (acute or ED), long term care or residential facilities (PRTF) to home

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Results of the initial and periodic assessment are used to assign enrollees to an acuity level (I-III). The acuity level determines the frequency of CCP and face-to-face visit interventions by the assigned Care Manager. CCP Face-to-Face Visits Level I Updated once yearly and as

warranted 1 visit/ year and as warranted

Level II Updated once yearly and as warranted

2 visits/year and as warranted

Level III Updated twice yearly and as warranted

3 visits/year and as warranted

Working with the Care Manager – what is the role of the Provider?

• Comply with EDSDT and adult preventive care requirements and guidelines • Collaborate in development of the Care Coordination Plan (review, edit, sign, and return) • Follow the HSCSN Referral Guidelines for services requiring preauthorization • Ensure that referrals for home care, durable medical equipment and medical supplies are

complete and that services are monitored as indicated • Communicate with the HSCSN Care Manager about concerns (risks, noncompliance,

overutilization, underutilization, health education needs, etc.) and progress

C. Utilization Management The purpose of HSCSN’s Utilization Management (UM) Program is to guide the structure and operation of utilization activities and to monitor, evaluate and manage the quality, cost and appropriateness of health care services delivered to enrollees of the health plan. UM activities are designed to assist the provider in the delivery of appropriate services to enrollees within our benefit structure. The centralized authorization team assists providers, facilities, and others in authorizing health care services for enrollees. HSCSN staff (nurses and social workers) work collaboratively with licensed, board-certified physician reviewers (medical and behavioral health) to conduct utilization review of requested services and equipment, and to coordinate care across the continuum. The UM program utilizes InterQual criteria, HSCSN internally developed criteria, and other guidelines for review of identified inpatient, outpatient, home health and durable medical equipment requests. i. Referrals and Authorization of Services HSCSN encourages the primary care provider (PCP) to coordinate specialty services for the enrollee. Prior authorization is not required for identified services to participating (in network) providers. The enrollee should possess a referral from their PCP, or other referring provider, to present to the service provider when presenting for an appointment.

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If a provider elects to refer enrollees to nonparticipating (out of network) specialists for any reason these requests must receive prior authorization from HSCSN before the enrollee accesses the service. The following services DO NOT REQUIRE prior authorization:

• Specialty office visits (except behavioral health) • Primary care visits • Well woman care (including Depo-Provera shots) • Vision services (including eye glasses) • Labs and Radiology (including X-Rays, sonograms, MRIs, CT and PET Scans) • Dialysis – End Stage Renal Disease

The following services REQUIRE prior authorization: (See Appendix A – Forms)

Behavioral • Psychiatric and Neuropsychiatric evaluations • Psychological testing and evaluations • Psychotherapy, Counseling and Applied Behavioral Analysis (ABA) • Psychotropic medication management visits • Intensive Outpatient Programs and Day Rehabilitative services • Partial hospitalization programs • Sub-acute admission • Substance Abuse treatment (inpatient and outpatient) • Psychiatric Residential Treatment Facility • Intermediate Care Facility for Mental Retardation (ICF-MR) • Dialysis – End Stage Renal Disease

Medical/Surgical • Early Intervention Services • Rehabilitative therapies (physical, speech, occupational) • OB Global services and services associated with pregnancy (See Appendix A – Forms) • Home health (nursing, personal care aide and rehab therapies) and hospice care • Durable Medical Equipment, Orthotics, Prosthetics, and Assistive Technology • Supplies and Nutritional supplements • Anesthesia for dental procedures (Ambulatory Setting) • Elective medical admissions (including feeding programs) • Facility admissions - Sub-acute, Rehab, Transitional and Long Term Care • Elective surgery (including plastic surgery), outpatient and inpatient • Home Modification

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Home Health Services – Medical Home health services (Skilled Nursing) must be ordered by a physician. The ordering provider must submit a completed HSCSN Home Care Referral Form prior to service initiation. The form will improve and expedite referrals, reviews and authorizations. The completed HSCSN Home Care referral form (See Appendix A – Forms) can be faxed to (202) 721-7190. The care requested must be appropriate to the home setting and to the enrollee’s needs. The request will be reviewed every 60 days within the Home Health Unit for medical necessity. The requesting provider must review and sign the plan of care from the home care agency every 60 days to ensure that services are appropriate and continue to be medically necessary.

Personal Care Aide Referrals and Authorizations

HSCSN requires an in-home assessment of the enrollee’s personal care needs by an RN prior to the initial authorization of services and a minimum of every six (6) months for ongoing services. The nurse assessment will assist providers in developing home care orders and monitoring home care goals. The assessment will provide the health plan with current, objective clinical information needed for medical necessity determinations.

1. The Provider Referral form (See Appendix A – Forms) will allow requests for assessment only (the provider will not be asked to specify hours and days for the requested service).

2. Within one (1) business day of receipt of the request, HSCSN will authorize an RN Assessment (RNA) by a contracted Home Health Agency (HHA).

3. The HHA must complete the RNA visit within 48 hours of the authorization. 4. The HHA must submit the HSCSN Personal Care Aide (PCA) Assessment

Form (See Appendix A – Forms) within one (1) business day of the visit for initial requests and within five (5) business days for ongoing cases to AuthCentralntake@hscsn.org or fax (202) 721-7190.

5. The HHA will use the RN Supervisory code T1001 to bill for RNA visits. 6. Within 48 hours of receipt of the RNA, the HSCSN Review Nurse will

determine PCA hours and frequency based upon activities of daily living information in the RN Assessment.

7. The HSCSN Review Nurse will submit a PCA Order Form with the authorized hours and days to the referring physician for review and signature.

Please call HSCSN at (202) 467-2737 and request to speak with the Home Health Review Nurse if you need assistance. Home Health Services – Behavioral Health The goal of our behavioral health home care service is to work with enrollees, their families and community providers to treat challenging behaviors that interfere with a youth’s successful functioning at home and in the community. In-home services are delivered by a trained Behavior Specialist and a supervising licensed behavioral health professional.

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The HSCSN Behavioral Health Home Services Referral Form (See Appendix A – Forms) must be submitted for all home-based behavioral health service requests. The form will improve and expedite referrals, reviews and authorizations. It is important that the provider supply all relevant clinical history. The completed HSCSN Behavioral Health Home Services Referral form can be faxed to (202) 721-7190. The requests are reviewed by the Home Health Unit and referred to an independent licensed social worker to conduct an assessment and provide recommendations for services. Behavioral health home services are authorized based on the recommendation. The services will be reassessed every six (6) months within the Home Health Unit for continued medical necessity. Please call HSCSN at (202) 467-2737 and request to speak with the Home Health Review Nurse if you need assistance. Medical Supplies and Nutritional Supplements Documentation required to determine medical necessity varies on the supplies requested. Please call HSCSN at (202) 467-2737 and request to speak with the DME Review Nurse if you need assistance. Durable Medical Equipment (DME), Orthotics, Prosthetics and Assistive Technology The documentation required for the authorization is dependent on the type of equipment requested. The following are standard requirements:

• Physician Order for the Service • Certificate of Medical Necessity (CMN) or Physician Letter

A pended authorization is generated after receipt of the CMN and the physician order. Delivery confirmation receipt from the vendor is required before an authorization can be approved. Please fax receipt to the DME Review Nurse within 24 hours of delivery at (202) 467-0978. Receipt should include the following information:

• Signature of person taking possession of equipment at time of delivery; • Delivery date; • Documentation of education conducted; and • Brand name, model number, quantity, serial/identification number(s) of equipment

delivered HSCSN verifies all new and replacement durable medical equipment, prosthetics, orthotics, and assistive technology delivered to the enrollees in the home. Inpatient Admissions Non-emergent (elective) medical/surgical inpatient admissions and outpatient surgical procedures must receive prior authorization from the UM Department. The PCP or specialist should contact the UM Department at least three (3) business days prior to the scheduled

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admission or procedure to obtain authorization. The medical information needed to assist in making a determination for medical necessity/appropriateness will be reviewed prior to authorization of the service. All emergent/urgent inpatient admissions must be reported to the UM Department within 24 hours of the admission. Please fax admission information to (202) 635-5590. The following information is needed for the admission:

• Enrollee Name • ID Number • Admitting Physician • Hospital Name and Address • Admission Date • Diagnosis and clinical information • Name and Telephone Number of Contact Person

If notification is not received within 24 hours of the admission, the day’s prior to notification will be denied unless there are documented extenuating circumstances. Once notification of an admission is received, and throughout the hospital stay, the UM Inpatient Review staff (medical and behavioral) will request clinical information on the enrollee to certify continued stay as an inpatient. The clinical information received is reviewed against InterQual Criteria and the admission is either approved or referred to the Physician Reviewer for further review. The UM Inpatient Reviewer, based on consultation with the Physician Reviewer, will notify the requesting provider of an adverse decision and discuss alternatives. If additional clinical information is requested and is not received within two (2) business days of the request, the days will be administratively denied for lack of clinical information.

ii. Behavioral Health Outpatient Mental Health Services Authorizations for medication management and therapy services (individual, group, family) are provided by the enrollee’s Care Manager in accordance with the table below.

Type of service requested

Benefit Initial Authorization Requirement

Continued Authorization Requirement

Medication Management

Plan allows 16 visits/year

Submit initial treatment plan

Updated treatment plan or submitted treatment report - required every 12 months

Individual, Group and Family Therapy

Plan allows 90 visits/six months

Submit initial treatment plan

Updated treatment plan or submitted treatment report – required every 6 months

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The behavioral health treatment plan (See Appendix A – Forms) or outpatient treatment report must be received by the Care Manager within 30 days of initiating services and every six (6) to 12 months for continued authorization, depending on the authorized service (see table). HSCSN does not accept psychotherapy notes. All mental health services for HSCSN enrollees are authorized through the Care Management and Utilization Management Departments. The Care Manager must receive appropriate clinical information to ensure that services requested are medically necessary and covered under the enrollee’s HSCSN benefits. HSCSN has a Board Certified Child and Adolescent Psychiatrist serving as Director of Behavioral Health, who oversees all medical necessity determinations for every level of care. The Residential Placement Review Committee (RPRC) The RPRC monitors all requests for admission to a Psychiatric Residential Treatment Facility (PRTF). The RPRC Committee requires an enrollee have a current psychiatric evaluation, as well as psychological testing before a decision is rendered regarding admission to a PRTF. Providers should submit all clinical information to the enrollee’s Care Manager for presentation to the committee. Documentation Standards for Mental Health Providers

- Signed consents for treatment and release of information

- Signed documents stating the professional status of the individual who rendered the service and dated on the day the individual signed the document.

- Each page of the enrollee’s records should have his/her name, ID number and birth date.

- Each encounter with an enrollee must be documented for every date of service billed. Enrollee Records Maintenance of all enrollee records must follow the guidelines below:

- All records will be stored in a safe and secure environment to maintain confidentiality - Records will be indexed and filed according to standard medical record procedures,

allowing for accessibility for patient treatment, timely documentation and availability of external review.

- Medical records for every enrollee will be retained in the provider files for a period of at

least 10 years, following the last encounter, and or at least three (3) years after the enrollee reaches legal age.

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- All providers must obtain a signed release of information form from a parent, legal

guardian, or enrollee of legal age prior to releasing any medical information regarding an enrollee to anyone other than HSCSN personnel.

Access to Alcohol and Drug Treatment Behavioral Health Practitioners and PCPs are responsible for identifying HSCSN Enrollees with active or potential substance abuse problems. Once those members have been identified the Behavioral Health Practitioners and PCPs are also responsible for contacting HSCSN care managers once the need for treatment has been identified. The HSCSN Care Manager is then responsible for referring Enrollees with Alcohol or Substance abuse treatment needs to the Addictions Prevention and Recovery Administration (APRA). HSCSN Enrollees referred for Alcohol or substance abuse treatment remains enrolled in HSCSN and the Care Manager remains responsible for coordinating all necessary health care. HSCSN enrollees are eligible for medically necessary care for acute medical conditions related to alcohol or substance abuse through APRA. APRA has a youth and adult intake center for all substance abuse services. This includes inpatient, outpatient and detoxification services. APRA makes the decision regarding the level of appropriate level of services and will also refer the enrollee to a substance abuse provider once an intake is conducted at one of the two centers.

For Adult Intake (age 18 and older):

Assessment and Referral Center 1905 Massachusetts Avenue, SE Building 12 Washington, DC 20003 (202) 698-6080

For Youth Intake (up to age 17):

Prevention and Youth Services 3720 Martin Luther King Avenue, SE Washington, DC 20032 (202) 645-0344

HSCSN Care Managers make the referral, follows enrollees referred for alcohol or substance abuse treatment and facilitate the enrollee’s transition back into the primary care setting.

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Access to Mental Health Services All residents residing in the District of Columbia are eligible for Mental Health Services through the District of Columbia Department of Mental Health (DMH). Mental health services can be access through DMH’s “Access Help Line.” Once referred to the Access Help line, members are referred to a Core Services Agencies who reviewed the referral and recommends the appropriate provider for each member’s specific needs. Providers are encouraged to contact the HSCSN Care Manager to assist with the referral to DMH’s Access Hotline and the coordination of additional medically necessary substance abuse treatment. Providers can access the Department of Mental Health Access Help Line at (202) 671-3070 or 1-888-793-4357. Determination Time Frames HSCSN utilizes the following time frames to make determinations for requested services:

1) Non-urgent pre-service determination (approval or denial) is made within 72 hours of receipt of request. Additional time (up to 14 days) is allowed if information necessary to make the decision is not received (an extension request will be sent to the requesting provider and enrollee documenting information needed for the decision). Enrollee and provider are notified of non-urgent pre-service determination within 72 hours of receipt of request

2) Urgent pre-service determination (approval or denial) is made within 24 hours of

receipt of request, including the collection of all necessary information (no additional time is allowed for obtaining information). Enrollee and provider are notified of urgent preservice determination within 24 hours of receipt of request.

3) Urgent concurrent determination (approval or denial) is made within 24 hours of

receipt of request, including the collection of all necessary information (no additional time is allowed for obtaining information). Enrollee and provider are notified of urgent concurrent determination within 24 hours of receipt of request.

Denials When requests received by HSCSN do not meet medical necessity criteria for approval our staff refers the case to a Physician Reviewer for final review and determination. A letter explaining the denial is provided to the enrollee, requesting provider, and PCP.

1. The Chief Medical Officer, Chief Psychiatric Medical Officer, or Physician Reviewer must review any request that does not meet criteria.

2. In all denied cases the provider(s) and enrollee are informed of the appeals process.

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3. The denial includes documentation of the relevant clinical information supporting the decision.

4. The Chief Medical Officer, Chief Psychiatric Medical Officer, or Physician Reviewer is available by telephone to discuss denial decisions with the providers.

5. Denial decisions will be communicated to the enrollee and provider in writing and within the appropriate time frames. The letters used for denials include:

• reason for denial, including an understandable summary of the UM criteria upon

which denial was based (i.e. a statement in laymen’s terms as to why the service was denied);

• reason includes a reference to the benefit provision, guideline, protocol or other similar criterion on which the denial decision is based;

• appropriate alternative care recommendations; • the means by which the Chief Medical Officer, Chief Psychiatric Medical Officer,

or Physician Reviewer may be contacted to discuss denial decisions; • notification that the member may obtain a copy of the benefit provision,

guideline, protocol or other similar criterion on which the denial decision is based, upon request;

• description of appeal rights, including the right to submit written comments, documents or other information relevant to the appeal;

• explanation of the appeal process, including the right to member representation and time frames for deciding appeals;

• if the denial is an urgent pre-service or urgent concurrent denial, a description of the expedited appeal process will be included.

Provider Rights

1. Discuss denial decisions with a Licensed Clinical Reviewer. 2. Speak with the physician reviewer who issued the denial (or designee). 3. Obtain an explanation of the appeals process, including timeframes for the appeal

decision. 4. Appeal a denial decision by submitting written comments, documents or other relevant

information.

iii. Appeals Process Appealing a Denial Decision The enrollee, provider, or other representative acting on the behalf of the enrollee may submit an appeal for any coverage determination issued by HSCSN. Coverage determinations include denial decisions, reduction, suspension, or termination of a previously authorized service. The provider can appeal a denial decision by submitting written comments, documents or other relevant information to HSCSN.

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Provider Rights to Appeal a Clinical Denial Decision Providers have the right to:

- Discuss denial decisions with the licensed clinical reviewer - Speak with the physician reviewer who issued the denial (or designee)

- Obtain an explanation of appeals process, including timeframes for appeal decision

- Appeal decision by submitting written comments, documents or any relevant information

To File an Appeal

There are two ways to file an Appeal:

1. Telephone the Utilization Review Line at (202) 721-7162 on Monday – Friday from

8:30am to 5:00pm 2.Health Services for Children with Special Needs, Inc.

Attn: Utilization Management Department - Appeals 1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

iv. Fair Hearing Process

If you disagree with the resolution of an appeal you have the right to request a Fair Hearing with the District of Columbia, Office of Administrative Hearings within 90 days from the date of the appeal determination notice. You also have the right to proceed directly to a Fair Hearing. To request a Fair Hearing, contact the following agency:

District of Columbia, Office of Administrative Hearings Clerk of the Court 441 4th Street, NW, Suite 450 North Washington, DC 20001 (202) 442-9094

If you need assistance filing a request for a Fair Hearing with the District of Columbia, Office of Administrative Hearings, you may contact HSCSN’s Customer Care Department at (202) 467-2737. You may also request assistance by sending a written request to:

Health Services for Children with Special Needs, Inc. Attn: Director, Risk Management 1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

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v. Medical Necessity Guidelines Utilization review is the process of determining whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. Medical necessity is based on symptoms and objective findings. The utilization review process is a mechanism used to evaluate health care services and enrollee needs. The main objective is to review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care delivery, and the need for planning subsequent care. Care Management/Utilization Management staff utilize nationally and internally developed criteria for medical necessity determinations. All criteria are reviewed and updated annually. The medical and behavioral criteria approved for the use by HSCSN for clinical determinations is InterQual Level of Care Criteria. HSCSN is licensed to utilize the criteria by McKesson Health Solutions, LLC. All InterQual criteria sets are based on two major clinical components: Severity of Illness and Intensity of Service; the sets are sub-grouped by body system, clinical findings, imaging findings, laboratory findings and daily treatment protocols. InterQual Criteria are guidelines that provide a licensed clinical reviewer with a baseline structure for assessing medical necessity; it is neither the sole resource for managing patient care nor the resource for denying patient care. When a proposed plan of care does not meet medical necessity screening criteria performed by a licensed nurse or social worker, the case is referred to an HSCSN Physician Reviewer for decision. The Physician Reviewer will consult with the treating physician to make a determination to approve or deny care services. If the care services are denied, the provider may request an appeal, which will be provided by an independent physician. Enrollees are notified in writing of all decisions, including their rights to appeal and the process for appeal. The following is a list of the criteria approved annually for use by HSCSN utilization review staff: McKesson InterQual: InterQual Level of Care Acute Criteria, Adult InterQual Level of Care Acute Criteria, Pediatric InterQual Level of Care Behavioral Health Criteria Chemical Dependency and Dual

Diagnosis, Adult and Adolescent InterQual Level of Care Behavioral Health Criteria Psychiatry, Adult InterQual Level of Care Behavioral Health Criteria Psychiatry, Child InterQual Level of Care Behavioral Health Criteria Residential Treatment, Adult,

Adolescent and Child InterQual Level of Care Home Care

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InterQual Care Planning Criteria Durable Medical Equipment Centers for Medicare and Medicaid Services (CMS) Coverage Issues Manual and

Medicare National Coverage Determination Manual Centers for Medicare and Medicare Services (CMS) National and Local Coverage

Determination Database for Durable Medical Equipment, Prosthetics and Orthotics Supplies (DMEPOS)

HSCSN internal criteria: HSCSN Home Health Care Services Criteria HSCSN Vision Therapy Criteria District of Columbia Sub Acute Criteria (Psychiatry) HSCSN Behavioral Health Home Services Policy and Criteria Dental Necessity Criteria

To obtain a copy of criteria: HSCSN Care Management/Utilization Management (CM/UM) staff and Physicians are available to address your questions regarding decisions relating to prior or ongoing authorization for any medical or behavioral service for an enrollee. If the treating physician would like to discuss this case with a physician reviewer, please call the CM/UM Department at (202) 721-7162. To request criteria, provide the specific criteria you are requesting with a fax number or mailing address. A synopsis will be provided free of charge. You will receive a faxed copy of the requested criteria within 24 hours or a written copy by mail within five (5) business days of your request. Medical Necessity Definitions A service is Medically Necessary for an individual if a physician or other treating health Provider, exercising prudent clinical judgment, would provide or order the service for a patient for the purpose of evaluating, diagnosing or treating illness, injury, disease, physical or mental health conditions, or their symptoms, and that is: - In accordance with the generally accepted standards of medical practice

- Clinically appropriate, in terms of type, frequency, extent, site and duration

- Considered effective for the patient’s illness, injury, disease, or physical or mental health

condition

- Not primarily for the convenience of the individual, Care giver, treating physician, or other treating health care provider

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- More cost effective than an alternative service or sequence of services, and at least as likely to produce equivalent therapeutic or diagnostic results with respect to the diagnosis or treatment of that individual’s illness, injury, disease or physical or mental health condition.

Medically Necessary services for enrollees under age twenty-one (21) include:

- EPSDT screening services;

- Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP);

- A health care, diagnostic service, treatment, or other measure described in Section

1905(a) of the Social Security Act, 42 U.S.C. § 1396d(a), to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the District of Columbia State Medicaid plan.

- Services and benefits that promote normal growth and development and prevent, diagnose, detect, treat, or ameliorate the effects of a physical, mental, behavioral, genetic, or congenital condition, injury, or disability.

- Medically Necessary interventions must reflect current bioethical standards and must

reasonably be expected to produce the intended results for children and to have expected benefits that outweigh potential harmful effects. The health care intervention should:

- Assist in achieving, maintaining, or restoring health and functional

capabilities without discrimination to the nature of a congenital/developmental abnormality;

- Be appropriate for the age and developmental status of the child; - Take into account the setting that is appropriate to the specific needs of the

child and family; and - Reflect current bioethical standards.

Additional Medically Necessary Services

- Court Ordered Services – Services ordered to be furnished to an enrollee by a

Court of competent jurisdiction.

- Transition Services – During the first 60 days after enrollment (i.e. the Transition Period), a service is medically necessary if it relates to the treatment that the individual was receiving immediately prior to enrollment.

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- Employment Examinations- If an Enrollee, regardless of age, requires a health examination as a condition of new or continuing employment; the examination will be considered medically necessary.

- HIV/AIDS- Services related to the screening, testing, diagnosis, counseling

and treatment of HIV/AIDS are medically necessary. HSCSN shall participate in DOH’s initiatives regarding HIV/AIDS.

- Public Health Emergency - A declared public health emergency, whether

naturally occurring or human-made shall constitute a finding of medical necessity, with respect to all covered services.

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III. Clinical Practice Standards

A. Primary Care and Specialty Services Primary care is the integration of services that promote and preserve health; prevent disease, injury and dysfunction; and provides a regular source of care for acute and chronic illnesses and disabilities. The Primary Care Medical Home serves as the usual entry point into broader health and human service systems and incorporates community culture, needs, risks, strengths and resources into clinical practice. The Primary Care Physician (PCP) shares with the family an ongoing responsibility for the enrollee’s health care. The American Academy of Pediatrics defines a Medical Home as the “provision of care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent.” Physician Selection Each enrollee selects a primary care physician (PCP). The PCP serves as the enrollee’s personal physician within the medical home and is responsible for coordinating all aspects of care with the care manager. The PCP is responsible for obtaining documentation from specialist or hospital encounters to ensure coordination and continuity of care. The PCP is responsible for reviewing and approving the HSCSN Care Coordination Plan. Physician’s Responsibilities HSCSN primary care physicians are responsible for providing or arranging for the following:

- Office visits

- Injections and immunizations

- Participation in the care coordination plan

- Health education

- Vision and hearing screenings

- Early and periodic screening, diagnosis and treatment (EPSDT) services for enrollees 22

and under

- Verification of eligibility and prior authorization for provision of care when appropriate

- Diagnostic services performed in the physician’s office and coordinate referral to participating laboratory and radiology providers, unless otherwise preauthorized

- Physical examinations

Clinical Practice Standards

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- Monitor and lead the management of all medical and behavioral services being provided to the enrollee, including pharmacy, subspecialty and ancillary services, home care, equipment and supplies

- Additional responsibilities of primary care physicians include:

- Compliance with HSCSN’s utilization management and quality management policies and

procedures - Compliance with HSCSN’s administrative policies and procedures - Maintaining comprehensive patient records that reflect acceptable documentation standards

The Medical Home The American Academy of Pediatrics defines a Medical Home as the “provision of care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent.” HSCSN strives to ensure that such a partnership exists between the primary care physician and the family of the enrollee. Care management staff carefully monitors communications, collaboration, coordination of services, and effectiveness of care between enrollees and their selected Medical Home. Care management staff also makes arrangements for “enabling services,” such as transportation and respite care, to complement customary health care and ensure accessibility. Specialty Care Physician In general, enrollees may not self-refer for specialty care and must receive specialty care referrals from their PCP. Prior authorization from HSCSN is not required for most outpatient specialty visits. HSCSN participating specialists are responsible for providing services within the scope of their specialty. It is the responsibility of the specialist to work closely with the PCP and Care Manager to enhance the continuity of medical care and recommend appropriate treatment. The specialist must also keep the PCP informed with written documentation. Ancillary Provider Enrollees receive ancillary care upon recommendation from their primary care physician. Prior authorization required for most ancillary services. In general, enrollees may not self -refer nor receive ancillary care services not listed on their plan of treatment without prior authorization from their PCP or care manager. Ancillary providers are responsible for providing services within the scope of their specialty. Working closely with PCPs and care managers, ancillary providers enhance continuity of medical care and recommend appropriate treatment.

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B. HealthCheck (formerly EPSDT) Standards of Care for Children

EPSDT also requires states to provide any medically necessary health care that falls within the scope of services listed at 42 U.S.C. § 1396d(e) to a child, even if the service is not available under the State's Medicaid plan to adults. Salazar v. D.C., 1997 WL 306876, at 8 (D.D.C). Court order requires the District of Columbia to establish a tracking system to assure that Medicaid- eligible children receive all age-appropriate screens and services as well as follow-up treatment. Standards of care for services rendered to HSCSN enrollees are based on the American Academy of Pediatrics manual, Guidelines for Health Supervision, and the Medicaid program for the District of Columbia, which advocates for Early and Periodic Screening, Diagnosis, and Treatment. Enrollee’s initial visit with a new PCP who has not previously cared for enrollee shall include a comprehensive initial examination and screening for mental health, alcohol, and drug abuse problems using a validated screening tool approved by the Department of Health Care Finance, and referrals for any additional tests or examinations needed in order to complete a comprehensive assessment of the enrollee’s health condition. Treatment planning shall be based upon a comprehensive assessment of each enrollee’s condition and needs. The enrollee’s family shall be actively involved in developing a treatment plan for any identified health conditions. PCP’s shall provide both a written and oral explanation of EPSDT services to enrollees, including pregnant woman, parents and/or guardians, child custodians and sui juris teenagers. This explanation shall occur on the first visit, and annually thereafter, and include the distribution of a pocket-sized card with the schedule for screens, laboratory tests, and immunizations. The importance of the preventive aspects of the service and the benefits of early developmental and anticipatory guidance services should be emphasized for children under age three (3) and their caregivers.

Anticipatory Guidance Appropriate discussion and counseling of parents with regard to their child’s growth, development and psychosocial issues should be an internal part of the office visit. Sensory Screening To evaluate sensory development, a vision screening should be administered to every child from the age of four and then once every one to two years. A hearing screening should be administered to every child from the age of four and then once every one to two years. Screenings are either done objectively or subjectively according to the periodicity schedule. Initial Dental Referral Initial dental screening should be done by age three and then periodically as recommended by the dentist. These standards may be performed earlier or more frequently as befits the medical status of the patient. Procedures Hereditary and metabolic screening should be done on every baby prior to discharge from the nursery and again at two to four weeks of age. Cholesterol screening should be performed any time after age two. However, family history may play an important part in how soon this measurement needs to be done. Immunizations should be administered as recommended by the American Academy of Pediatrics Report of Committee on Infectious Disease or Advisory Committee for Immunization Practices. Developmental Assessment A developmental screening and behavior assessment should be administered to every child from birth to determine neurodevelopment or psychosocial status. Measurements For all children who are receiving regular preventative care, and are given a “well child” or health assessment, a complete history and physical examination should be done on a yearly basis. This should include height and weight as well as head circumference (in the first year of life). A blood pressure reading should be taken on all children from the age of three on a yearly basis.

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HSCSN Care Managers play a key role to maximize EPSDT efforts and to facilitate our goal of 100 percent compliance. What HSCSN does to encourage enrollees toward HealthCheck compliance?

- Monitor HealthCheck status of all enrollees including lead, immunizations (and routine dental)

- Inform enrollees when they are due based on periodicity (DOH) via phone/letter

- Encourage our enrollees to schedule appointments

- Offer to assist with scheduling HealthCheck related appointments and arrange transport

- Offer ongoing assist/outreach to maximize compliance with all HealthCheck related services including routine dental care

- Send out EPSDT related brochures and appointment reminder cards

- Educate by phone, loop tape or by enrollee newsletters

- Outreach Department plays a key role in educating our enrollees both upon enrollment and with face to face outreach efforts related to HealthCheck compliance

Provider Assistance

- File Electronic claims if capable - Other Claims (as soon as possible)

- Accurate coding upon billing

- Reporting to lead and immunization registries as soon as possible

- Encounters if requested

- Keep us abreast of no-shows; HSCSN’s Family and Community Development

Department will conduct face to face visits

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The DC Department of Health Care Finance (DHCF) in partnership with Georgetown University has developed HealthCheck Training and Resource Center to address your training needs. Please register at http://dchealthcheck.net to review the curriculum. Your registration ensures that your training is recorded by DHCF. This is necessary so that you get credit for fulfilling the training obligations required to be a Medicaid provider. Please note that the HealthCheck training will fulfill your obligations for all Medicaid Managed Care Organizations (MCOs) with which you are paneled:

• AmeriHealth DC • Health Services for Children with Special Needs, Inc. • MedStar Family Choice • Trusted Health Plan • Fee-For-Service Medicaid Providers

For the HealthCheck training, you will receive 5 CMEs upon completion of the curriculum*. Online Training:

• Online HealthCheck training is fast and easy to complete • Fulfills Medicaid training requirements and provides 5 CME credits • CME credits will be paid for by the MCOs when you are due for HealthCheck training.

(Providers must be trained once every 2 years). Register at www.dchealthcheck.net to check your training status.

Online Resources:

• Documentation guidelines: EMRs, billing codes/procedures • Provider resources: DC contacts, Early Intervention resources, Bright Futures materials • Special health issues: dental health, obesity, abuse/neglect

* MedStar Georgetown designates this curriculum for a maximum of 5 hours in category 1 credits towards the AMA Physician’s Recognition Award.

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C. Supplemental Security Income (SSI) Program The Supplemental Security Income (SSI) program remains an important source of financial support (a monthly stipend is provided by the federal government) for low-income families of children with special health care needs and disabling conditions. The Social Security Administration (SSA), which administers the SSI program, considers a child disabled under SSI if there is a medically determinable physical or mental impairment or combination of impairments that results in marked and severe functional limitations. The impairment(s) must be expected to result in death or have lasted or be expected to last for a continuous period of at least 12 months. The income and assets of families of children with disabilities are also considered when determining financial eligibility. When an individual with a disability becomes an adult at 18 years of age, the SSA considers only the individual’s income and assets. The SSA considers an adult to be disabled if there is a medically determinable impairment (or combination of impairments) that prevents substantial gainful activity for at least 12 continuous months. SSI benefits are important for youth with chronic conditions who are transitioning to adulthood. Disability Determination Each state has an agency that makes disability determinations on behalf of the SSA. States use a variety of names for these agencies; however, they are generically known as disability-determination services (DDSs). The DDS agency uses a team that consists of a disability examiner and medical or psychological professionals to decide whether a child is eligible for SSI on the basis of the available medical and nonmedical evidence. The decision-making team attempts to develop a complete medical and functional history for the child for at least the 12 months preceding the application for SSI. DDS staff members do not examine the child. The determination of disability by the DDS agency is based primarily on the written information submitted, especially the child's medical records. It is essential for pediatricians and other professionals to forward appropriate records or to provide a complete, detailed summary report. Role of the Primary Care Physician The role of treating physicians is to provide accurate, timely, impartial information, not to decide whether an individual is disabled. The DDS team will make the disability decision by using information from the primary care physician and many other sources. The medical report in support of a child’s application for SSI should:

• use specific terms and include results from specific clinical tests (if obtained); • include at least a 12-month medical history of the child; • provide complete, detailed clinical findings (including results of physical, intelligence,

developmental, and mental status examinations); • include complete, detailed laboratory findings (eg, XRays, chromosome tests, etc); • specify the diagnosis (on the basis of signs, symptoms, and laboratory findings); • review treatments prescribed with response and prognosis; • state the probable duration of the impairment; • include an assessment of the child’s physical or mental abilities to function in an age-

appropriate manner and to perform age-appropriate daily activities; and

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• describe the nature and limiting effects of the impairment(s) on the child’s ability to function in an age-appropriate manner and to perform age-appropriate daily activities.

Resource: Policy Statement: Supplemental Security Income for Children and Youth with Disabilities. The American Academy of Pediatrics, 2009. For more information, go to www.ssa.gov or www.aap.org.

D. Individuals with Disabilities Education Act (IDEA) The following article is an excerpt from an American Academy of Pediatrics article on the 1991 Individuals with Disabilities Education Act (IDEA). It provides an excellent background on the law and the pediatrician’s role in the process of ensuring that children with disabilities share the same right to a free and appropriate education as children without disabilities. The Pediatrician’s Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP) ABSTRACT The Individual Education Plan and Individual Family Service Plan are legally mandated documents developed by a multidisciplinary team assessment that specifies goals and services for each child eligible for special educational services or early intervention services. Pediatricians need to be knowledgeable of federal, state, and local requirements; establish linkages with early intervention, educational professionals, and parent support groups; and collaborate with the team working with individual children. Special education in each local school district is protected and regulated by strong legislative and judicial safeguards created by the federal Education for All Handicapped Children Act. This act was reauthorized in 1991 legislation under the new title, Individuals with Disabilities Education Act (IDEA), which has four key components: These federally legislated safeguards establish that children with disabilities and their parents share the same legal right to a free and appropriate education as children without disabilities. Federal legislation requires that each child recognized as having a disability that interferes with learning has a written plan of service: an Individual Education Plan (IEP) for children aged 3 through 21 years, an Individual Family Service Plan (IFSP) for infants and toddlers birth through three (3) years and a Transitional Services Outcome Plan for young adults at 16 years of age. Federal legislation defines transition from school as a coordinated set of activities for a student designed to promote movement from school to post-school activities, including post-secondary education, vocational training, integrated employment, continuing and adult education, adult services, independent living, and community participation. This transition plan highlights and validates the lifelong needs of individuals with disabilities and is the beginning of an integrated program that enables adults with disabilities to live, work and play in our towns and cities. The pediatrician is in a key position to participate in planning services and to provide care for these children and young adults.

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KEY COMPONENTS OF IDEA

- Identification of children with learning-related problems - Evaluation of the health and developmental status of the child with

special needs, determine current and future intervention requirements and developing a plan to match services to needs.

- Provision of services that include educational and related services - Guaranteed due process

The Individual Education Plan (IEP) BACKGROUND In 1975, Congress enacted PL 94-142, the Education for All Handicapped Children Act, as an educational bill of rights to assure children with disabilities a free and appropriate education in the least restrictive environment. In 1977, implementation of services was extended to children 3 to 21 years old, although services for children aged 3 to 5 years remained optional. States were also requested to identify children who had not previously received services. PL 94-142 (currently Part B) allowed children with mental retardation, hearing deficiencies, speech and language impairments, specific learning disabilities, visual impairments, emotional disturbances, orthopedic impairments, and a variety of medical conditions that may interfere with education (categorized as Other Health Impaired (OHI) to receive special education services. To meet eligibility criteria, a child’s disability must interfere with the educational process and normal school performance to the extent that special education assistance is needed. Other portions of the law provide the following: Every child must have a multidisciplinary evaluation by a team. This team, working in collaboration with the family, is responsible for designing an IEP that has specific education and therapeutic strategies and objectives. Each plan must be reviewed annually. Every child must be educated in the least restrictive environment. This criterion supports the concept of integrating children with and without disabilities as much as possible and with extra supports and services when necessary to facilitate inclusion. The evaluation team may recommend the following related services: Transportation, developmental, corrective, and other supportive services (including speech pathology, audiology, psychological services, and physical and occupational therapy); recreation (including therapeutic recreation); and social work services (including rehabilitative counseling) and medical services (for diagnostic and evaluative purposes only). These services may be required to assist a child to benefit from special education and include early identification and assessment of disabling conditions. If the parents approve the IEP, they sign a document and the school is committed to providing these outlined services.

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The rights of the parents and child to “due process” shall be protected. This ensures the parents’ rights to be involved in developing the educational plan and for the meeting to be conducted in their native language or other mode of communication if it is not a written language understandable to the general public. The IEP/IFSP team leader is responsible for arranging and paying for an interpreter if English is not the native language of the home or if the parent has a hearing impairment. Furthermore, parents have the right to appeal when they view the team’s decision as inappropriate or harmful. The Individual Family Service Plan (IFSP) BACKGROUND In 1986, Congress enacted the Education of the Handicapped Act Amendments, PL99-457. It was reauthorized in PL 105-07 in 1997. Part C of this reauthorization legislation, formerly known as Part H, called for the creation of statewide coordinated, multidisciplinary, interagency programs for the provision of early intervention services for all infants and toddlers with disabilities. Although the law did not mandate these services, partial reimbursement of costs was made readily available to states that wished to participate. All states have established programs for children birth to 3 years. These developmental services are designed to meet needs in the areas of physical, cognitive, communicative, and psychological development, and in self-help skills. The purpose of these services is to enhance the development of the infant and toddlers with disabilities; to minimize their potential for developmental delay; and to optimize the abilities of the families to meet the special needs of their children. It was also hoped that this would minimize the cost over time of special education services when youngsters attained school age, decrease the need for institutionalization, and enhance the potential for independent living. The law requires each state to create its own definition of developmental delay as a basis for determining eligibility for services. Pediatricians played a significant role in determining this eligibility by advocating for a broad definition of developmental delay. Services are provided for children with developmental delay, as well as for those whose biological conditions have a high probability of having a delay. In addition, states have the option to provide services to those children who are at risk of manifesting developmental delays attributable to environmental factors. A major difference between Part C and Pl 105-17 and Part B of PL 94-142 is that Part C focuses on the involvement of the family and supports for the family. Under this law, the evaluation, assessment, and planning take place with family participation and approval. Early intervention services are all optional, subject to family approval, and are provided in natural settings such as the parents’ home and child care settings as well as more formal child development programs. The current discussions about early brain development center on children from birth to 3 years. It is during this period that the growth and organization of the brain is most influenced by environmental factors that Part C strives to make optimal. Children referred as potentially eligible receive a comprehensive multidisciplinary assessment. The assessment describes the abilities and needs of the child and family. Following assessment, an IFSP is created, to include the following:

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- The child’s present attainments

- Family strengths

- How to enhance development of the child

- Major outcomes expected, including the outcome measures and criteria, and time lines to

achieve specific goals

- Specific early intervention services that the child and family will receive

- Projected dates for initiating services and their duration

- Name of the service coordinator responsible for coordinating and helping the family implement the plan

- Steps to help the child and family with the transition to school services at an appropriate time.

The statute specifies a wide array of other services, but the only health services included are those that are “necessary for the infant or toddler to benefit from other early intervention services.” Diagnostic and consultative medical services are also included, but the extent to which these services are funded by the early intervention program varies. Medical Role and Recommendations Several roles for the pediatrician exist under IDEA. All pediatricians should ensure that in their practices, every child with a disability has access to the following services: A medical home – A medical home provides care that is accessible, continuous, comprehensive, family-centered, coordinated, and compassionate. For children with special health care needs, many of whom have an IEP or an IFSP, the pediatrician’s central role as the provider of primary care means that he or she would participate in the plan development. In addition, the pediatrician should collaborate with community resources in treatment planning and in promoting early intervention programs that work. Screening, surveillance and diagnosis – The pediatrician should screen all children from the first encounter, checking for risk or existence of a disability or developmental delay. Pediatricians are in key positions to identify at the earliest possible age those children who may benefit from services under IDEA. Pediatricians should provide screening and surveillance using a combination of methods best designed to take advantage of multiple sources of information. Referral – The pediatrician should be knowledgeable about the referral process to early intervention programs in his or her community and knowledgeable about the parents’ right for multidisciplinary team evaluation by the school-or-state-designated agency if a disabling

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condition may be present. In addition, some of the best support of parents comes from other parents who are able to offer emotional and social support and practical advice. Many communities have programs in which parents support each other and help parents new to the system better navigate the system. Family Voices, a nationwide grassroots network of families and friends speaking on behalf of children with special health care needs, is a creditable organization that can assist parents and pediatricians and is accessible by telephone and the Internet (888-835-5669; www.familyvoices.org). Diagnosis and eligibility – For early intervention, the pediatrician has an important role in the identification of children with established delays and in the diagnosis of conditions with a high probability of developmental delay, which will qualify a child for this program. Each state has developed a definition of those conditions, which should be obtained from the state’s lead agency for this infant and toddler program. In addition, some states include “at risk” conditions as defined by the state as eligible for services. Further information about these issues can be obtained from the single point of entry into Part C locally or the state’s lead agency. A list of lead agencies for state early intervention services can be obtained from the National Childhood Technical Assistance System (919-962-2001); www.nectas.unc.edu). Participation in assessment – A child identified through screening or observation as meeting the definition for developmental delay should receive a comprehensive multidisciplinary assessment. The pediatrician has an important role as a referral source or, if more extensive participation is elected, as a member of the multidisciplinary team. Few pediatricians have the flexibility in their schedules to participate in person in lengthy team meetings. Usually, these meetings are scheduled with a short lead time and at the convenience of the educators arranging them. However, all pediatricians should offer to be available by written communication or participate by conference call or other means to offer input to and receive feedback from the assessment team. Ideally, the pediatrician should be a member of the team and attend the IEP/IFSP meeting. Counsel and advice – During the assessment process, families will need a knowledgeable person for medical advice and counsel. Pediatricians can alert parents to the benefits of a pre-IFSP or pre-IEP conference; of their right to sign the IFSP or IEP only when they are comfortable with the recommendations; and their right to have a friend or other advocate at the IFSTP and IEP conference. Although a parent may bring their personal attorney to the conference, most parents do not. If an attorney is going to attends on behalf of the family, the family should notify the school agency of that fact before the meeting to give the school an opportunity to have their legal counsel or top administrator scheduled for the conference. The appeal process begins at the district school board where the child resides. The president of the school board and superintendent of schools should receive the written appeal document. If appeal at the district level fails to satisfy the family’s concerns, their next appeal is to the State Board of Education. Rarely does an appeal by either the school district or family go to state or federal supreme courts. Each district school board has a published document that advises parents of procedural safeguards, which can be obtained at no cost to the family. Most assessment teams nominate a member as service coordinator to work with the families.

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A strong link should be developed between the assessment team and the primary care pediatrician, as well as an open sharing of concerns between parents, the pediatrician, and the assessment team. Creation of the IEP and IFSP – Pediatricians who participate in the assessment process should be consulted by the assessment team when these documents are created. Such consultation is vital to preparing an appropriate and effective plan. The pediatrician should review the plan developed, counsel the family, and comment on health-related issues as needed. The pediatrician should determine if the health-related services proposed are appropriate and sufficiently comprehensive and assist parents in performing their advocacy tasks when there is evidence of inappropriate planning. Ideally, when schools or educational agencies are developing the IEP or IFSP, a pediatrician should serve as a member of the assessment team. Coordinated medical services – When medical services are part of the IEP or IFSP, they should be conducted by the primary care pediatrician or an appropriate pediatric sub-specialist. Medical services and communication should be coordinated by the primary care pediatrician or his or her designee in those cases in which the children have complex medical needs involving several physicians or centers. Special education personnel should be made aware of the restrictions of health care insurance including limited referral options and the role of the primary physician as “the gatekeeper” in some programs. Advocacy – Pediatricians have many local and state opportunities to serve as knowledgeable, thoughtful advocates for improved community and educational services for children with disabilities. Pediatricians who select this role need to be aware of the structure of services in the community and the key persons who implement them. Examples of advocacy roles for pediatricians include participation in the local or state early intervention interagency council, consulting with the local school system or state department of education, or becoming a school board member. CONCLUSION Participation in interdisciplinary efforts for children with disabilities can help the pediatrician focus on the needs of the child with disabilities or developmental delay and improve the coordination of all forms of service and care for the child and the child’s family. The pediatrician’s role in IEP and IFSP development and implementation includes knowledge of federal statutes and state and local mandates and regulations; establishing linkages with local early intervention and education professionals and parental support groups; and collaborating with the team serving the individual child. Collaboration among parents, pediatricians, and educators can lead to better quality of care and paves the way for a better quality of life for the child and young adult with a disability.

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E. Adult Care An adult is defined as anyone over 18 years or an emancipated minor.

Annual Exam for Females Annual Exam for Males

- Medical history - Medical history - Height, weight and blood pressure - Height, weight and blood pressure - Physical exam - Physical exam - CBC - CBC - Urinalysis - Urinalysis - TB Screening - TB Screening - Breast Exam - Pap smear and other tests deemed appropriate

(Abnormal Pap smears should be followed at more frequent intervals).

F. Vaccines for Children

The Immunization Registry is a great tool to help providers properly immunize children. As of today, more than 58 “Vaccinations for Children” (VFC) sites, with multiple persons at each site, are connected to the registry, as well as many other health care practices, MCOs and agencies. The Registry staff processes over 10,000 records per month and faxes approximately 450 records per month to health care providers and other sites. The Registry internet site is used more than 6,000 times each month to view records and run reports. Providers who are connected to the registry are able to:

- Report demographic data and current and past immunizations on each child in their practice to the immunization program

- Report subsequent doses of vaccine as administered to patients

- Receive monthly vaccine usage reports automatically from the Registry. The Registry generates this report from the information that each provider submits monthly

- Receive immunization records from the Registry on clients in their practice

- Receive an assessment of the immunization rates for clients in their practice, and receive a profile of children vaccinated in their practice automatically from the Registry (eliminates the need to estimate this annually for the VFC Program).

The Registry staff provides ongoing technical assistance and on-site training. If you are currently linked with the Registry and have questions or concerns, please contact the Registry Staff at

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(202) 576-7130, ext. 7. Any providers interested in linking with the Registry should contact call (202) 576-7130 ext. 26. It is important that children be immunized and protected against preventable childhood illnesses. In addition to screenings and assessments, providers must also ensure that enrollees have up-to-date immunization records. Above is a list of the recommended vaccinations and schedule of admittance.

G. Dental The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate. Visit the American Academy of Pediatric Dentistry at www.aapd.org for all definitions, oral health policies, and clinical guidelines.

H. Clinical Practice Guidelines HSCSN encourages the use of evidence-based guidelines to ensure that the best and most current quality of care is provided to enrollees. All clinical practice guidelines adopted by HSCSN are reviewed every two years and can be found online at www.hscsn-net.org. The following guidelines have been approved by HSCSN for use by the provider network:

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents American Academy of Pediatrics http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf Clinical Practice Guideline: Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity Disorder American Academy of Pediatrics http://pediatrics.aappublications.org/content/108/4/1033.full.pdf Guidelines for the Diagnosis and Management of Asthma National Heart, Lung and Blood Institute http://www.ncbi.nlm.nih.gov/books/NBK7232 Clinical Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children American Academy of Pediatric Dentistry http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf Guideline on Management of Dental Patients with Special Health Care Needs American Academy of Pediatric Dentistry http://www.aapd.org/media/Policies_Guidelines/G_SHCN.pdf

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Standards of Medical Care in Diabetes American Diabetes Association http://care.diabetesjournals.org/content/36/Supplement_1/S11.full Type 2 Diabetes in Children and Adolescents American Diabetes Association http://care.diabetesjournals.org/content/23/3/381.full.pdf Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection National Institutes of Health http://www.aidsinfo.nih.gov/ContentFiles/PediatricGuidelines.pdf Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Health Care Settings Centers for Disease Control and Prevention http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf Routine HIV Testing District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD and TB Administration http://doh.dc.gov Perinatal HIV Testing District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD and TB Administration http://doh.dc.gov Recommended Immunization Schedule for Persons Aged 0-18 Years; Catch-up Immunization Schedule for Persons Aged 4 Months to 18 Years Centers for Disease Control and Prevention http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html The Initial Reproductive Health Visit American College of Obstetricians and Gynecologists http://www.acog.org/from_home/publications/immunization/co460.pdf Sexually Transmitted Diseases Treatment Guidelines Centers for Disease Control and Prevention http://www.cdc.gov/std/treatment/2010 Psychosocial Risk Factors: Prenatal Screening and Intervention American College of Obstetricians and Gynecologists http://www.ncbi.nlm.nih.gov/pubmed/16880322 Prevention of Pediatric Overweight and Obesity American Academy of Pediatrics http://pediatrics.aappublications.org/content/112/2/424.full Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity American Medical Association http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/obesity/childhood-obesity/assessment-prevention-treatment.page

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Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity – Implementation Guide National Initiative for Children’s Health Care Quality http://obesity.nichq.org/resources/expert%20committee%20recommendation%20implementation%20guide

HSCSN provides the criteria and guidelines to providers when requested and in compliance with copyright laws.

I. Advance Medical Directives In order to protect the rights of competent patients, aged 18 or older or an emancipated minor, HSCSN will provide written information to enrollees on their rights under State law 42 C.F.R. sec. 489.100 to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives and appoint Durable Power of Attorney for Health Care in accordance with Federal Patient Self Determination Act 1990 42 USC 1395 cc (a). Providers are expected to comply with government mandates regarding advance directives education for enrollees aged 18 or older. Educational materials for enrollees are available upon request.

- Advanced directive means a written instruction such as a living will or durable power of attorney for health care recognized under State law (whether statutory or as recognized by the courts of the State) relating to the provision of such care when the individual is incapacitated.

Types of Advanced Directives

- Living wills and medical powers of attorney are types of advance directives. A living

will, also called a treatment directive, documents personal wishes about end-of-life medical treatment in case decision-making or communication abilities are lost.

- A medical power of attorney is a legal document that lets you appoint someone (usually

called a health care agent or health care proxy) to make medical treatment decisions for you not only at the end of life but any time you are unable to speak for yourself.

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Procedure - Customer Care Services will provide Advanced Directives and Power of Attorney

information including a brief description of the applicable State law at the time of enrollment of the individual as part of the parent and member handbook.

- The information must address the following rights:

⋅ The right under state law for the enrollee to make decisions concerning medical care including the right to accept or refuse medical treatment and the right to formulate advance directive.

⋅ The right under state law that requires the organization to respect the implementation

of the right to make decisions regarding care and the right to formulate an advanced directive.

- Care Management staff will document in the care coordination records when an advanced

directive has been implemented by an enrollee when known. The organization will comply with the requirements of State law respecting advance directives.

J. Mandatory Reporting

Reporting Requirements for Providers By law, providers must report all occurrences of sexually transmitted diseases, communicable diseases, vaccine preventable diseases, immunizations administered, lead levels and developmental delay in infants and children to the following organizations:

Sexually Transmitted Diseases, Communicable Diseases Department of Health (202) 727-6408 Immunizations, Dept. of Health (Vaccine for Children) (202) 576-7130 Lead Levels, DC Lead Registry (202) 535-1398 Developmental Delay – DC Early Intervention (202) 727-3665 or visit www.strongstartdc.com

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IV. Quality Standards

A. Quality and Performance Improvement Program

Health Services for Children with Special Needs, Inc. (HSCSN) maintains an active Quality and Performance Improvement Program. For the purposes of oversight and assessment of the health plan enrollees and to ensure that the children, youth, adolescents and young adults with special health care needs have access to appropriate, essential, quality care, service and cost effective health care. The program focuses on the performance of organization-wide functions that significantly affect enrollee health outcomes of the enrollees and their families about the quality, safety and value of the services being provided. This program will serve to guide the organizational structure and operation of quality measurement and improvement activities through the incorporation of our mission, vision, values and guiding principles into the Quality and Performance Improvement Program and fulfillment of such through the Quality and Performance Improvement Plan. HSCSN’s Quality and Performance Improvement Program incorporates and aligns with the DHCF’s goals, as defined in its Continuous Quality Improvement Plan for Oversight & Assessment of Medicaid Managed Care Organizations and incorporates all applicable Department of Health (DOH) initiatives. Quality and Performance Improvement Program Goals

1. Availability/Access of Services a. Maintain a Network of Appropriate Providers; Sufficient in Number, Mix,

Geographical Distribution and Cultural Competency b. Promote and Monitor Access to Services. c. Maintain a Process for Credentialing and Re-credentialing of Physicians and

other Licensed Health Care Professionals d. Actively Promote the Delivery of Ethical, Culturally Competent Care

2. Facilitate the Development of a Multi-disciplinary Treatment Plan through

Collaboration and the Monitoring of Continuity of Care and Periodic re-assessments.

3. Ensure the Coordination of Health Care Services, Case Management and Ensure the Inclusion of Cultural Considerations.

4. Ensure Organizational Policies and Procedures are in place for Addressing

Compliance with all Applicable Privacy, Confidentiality, Information Security Requirements, Language Access and the provision of Interpreter Services and Periodic Training/Education of staff.

5. Maintain an Effective Utilization Management Program as well as an Annual

Program Evaluation.

Quality Standards

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6. Maintain an Effective Risk Management Program and an Annual Program Evaluation.

7. Facilitate a Culture of Safety by Emphasizing the Importance of Member Safety and

the Development of a Member Safety Program and Annual Evaluation.

8. Adoption/Implementation of Clinical Practice Guidelines based upon valid/reliable clinical evidence or consensus, updated periodically, as appropriate.

9. Maintain an Effective Quality and Performance Improvement Program with the

inclusion of QI Work Plan and Annual Evaluation.

10. Satisfaction Assessment of Enrollee, Family/Caregiver and the Provider Network.

11. Comply with External Quality Review Organizations, Accreditation, Certification and other Regulatory Entity Standards.

Quality Improvement Process Model HSCSN evaluates the development of new processes as well as the redesign or improvement of existing processes. A system approach is utilized to:

• Identify the new process or potential improvement • Assess/test the strategy for change • Analyze data from the test (to determine if the change produced the desired results) • Implement the improvement strategy system-wide when applicable

The PDCA Cycle includes the following steps:

PLAN – Plan to improve outcomes by finding out what things are going wrong (Assessment Phase) and coming up with ideas for solving these problems (Development Phase) DO – Do pilot the changes designed to solve the problems first. This minimizes disruption to routine activity while testing whether the changes will work or not. CHECK – Check whether the pilot achieved the desired result or not. Continuously Check outcome measures to ensure you know what the quality of the output is at all times and to ID any new problems when they crop up. ACT – Implement changes on a larger scale if the pilot is successful.

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B. External Quality Review Organization (EQRO) The intent of the Medicaid program is to improve access to care, promote disease prevention, ensure quality care and reduce Medicaid expenditures. To ensure that the care provided meets acceptable standards for quality, access and timeliness, the Department of Health Care Finance is charged with the responsibility of evaluating the quality of care provided to recipients enrolled in a contracted health plan and assessing the effectiveness of its Continuous Quality Improvement (CQI) program. The Department of Health Care Finance contracts with the Delmarva Foundation to serve as the External Quality Review Organization (EQRO) to conduct this annual evaluation. In accordance with federal regulations, Delmarva assesses the effectiveness of Health Services for Children with Special Needs, Inc. (HSCSN) Quality and Performance Improvement Program by utilizing performance standards based on the Balanced Budget Act (BBA) of 1997 and federal external quality review regulations. The BBA is the comprehensive revision to federal statutes governing all aspects of Medicaid managed care programs and prepaid inpatient health plan as set forth in Section 1932 of the Social Security Act and Title 42 of the Code of Federal regulations (CFR), part 438 et seq. The evaluation consists of an Operational Systems Review (OSR) assessing compliance for the following categories:

- Enrollee Rights - Quality Assessment & Performance Improvement - Grievance Systems - Centers for Medicare and Medicaid Services (CMS) document, “A Health Care Quality

Improvement System (HCQIS) for Medicaid Managed Care” The annual OSR is a mandated activity per our CASSIP contract with the District of Columbia Department of Health Care Finance and the BBA external quality review regulations.

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C. Healthcare Effectiveness Data and Information Set (HEDIS®)

Thank you for your continued support of our annual HEDIS (Healthcare Effectiveness Data and Information Set) reviews. HEDIS is a program designed and Managed by the National Committee on Quality Assurance (NCQA). The program is designed to measure a set of quality indicators and then be able to make comparisons across the nation based on plan type. HSCSN posts our results on our website and in our Provider Newsletter annually. You as a provider may also receive information throughout the year on your personal provider status with these measures as well as our overall health plan status. These are tools to help us partner to improve outcomes with the care delivery system for our enrollees. Because of all of your hard work HSCSN continues to perform well in many of the HEDIS measures. Improving the health status of our enrollees is important to all of us. As network providers you are instrumental in the delivery of the highest quality of care to HSCSN’s enrollees. As we work to improve our HEDIS scores we need your assistance and continued support. What can HSCSN’s network physicians do? Diabetes Care

1. Educate on the importance of eye exams, lipid control, blood pressure control, foot exams, and serum glucose control. Tight management of diabetic enrollees to assist in meeting HEDIS goals is recommended. The goals for good Diabetic Management are:

a. Lipid control = LDL-C < 100mg/dL b. HbA1C = < 7% good control, < 8% control, > 9% poor control c. BP = < 130/80 good control, < 140/90 poor control d. Annual medical attention for nephropathy

2. Refer enrollees to ophthalmologists/optometrists at least every two years. 3. Encourage enrollees to have ordered labs drawn. 4. Contact HSCSN Care Management when enrollees cancel appointments. 5. Ensure that diabetic patients receive a comprehensive examination annually. 6. Code information on your claims to document care delivery (Table 1).

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Table 1: Diabetic Values

Description CPT Category II Most Recent HbA1c >9.0% 3046F Most Recent HbA1c <8.0% 3044F Most Recent HbA1c <7.0% 3044F Most recent LDL-C < 100 mg/dL 3048F Most recent LDL-C 100-129 mg/dL 3049F Most recent LDL-C ≥ 130mg/dL 3050F Positive Microalbuminuria 3060F Negative Microalbuminuria 3061F Positive Macroalbuminuria 3062F Documentation of treatment for nephropathy (e.g. Dialysis, ESRD, CRF, ARF, RI or visit to nephrologist)

3066F

Description CPT Category II

Systolic Diastolic Most recent BP <130/80 mm Hg 3074F 3078F Most recent BP 130-139/80-89 mm Hg 3075F 3079F Most recent BP ≥140/90 mm Hg 3077F 3080F

Monitoring of BMI and associated components of good health In order to target Obesity and malnutrition and begin interventions as early as possible for both of these conditions it is accepted that monitoring of BMI and tracking what percentile and enrollee falls in is the most reliable way to date of determining where an enrollee is in the growth cycle. HEDIS also looks for documented discussions surrounding nutrition and exercise between the physician and caregiver or enrollee. Coding can also be used for all of these measures to document your care (Tables 1 & 2): Table 2: BMI for ages 17 and above

HCPCS ICD-9-CM Diagnosis G8417-G8420 V85.0-V85.5

Table 3: BMI and counseling for ages 3-17

Description CPT ICD-9-CM Diagnosis HCPCS

BMI percentile V85.5 Counseling for nutrition 97802-97804 V65.3 G0270, G0271, S9449, S9452, S9470 Counseling for physical activity V65.41 S9451

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Childhood Immunizations HEDIS looks at the Immunizations recommended by the CDC as an area of comparison for quality care. The Childhood immunization measure most specifically counts recommended immunizations that have been given PRIOR to the child’s second birthday. Immunizations that have been recommended to be given prior to 24 months of age that are given after the child’s second birthday are considered non-compliant.

1. Rotavirus administration is low, this may be because you must document if you are giving the two doses or three dose vaccines. If there is no documentation it is assumed the three dose vaccine was used and one dose was missed.

2. Rates of administration of the Influenza vaccine have been low in the last few years. This is a CDC recommendation that influenza vaccines be administered to children under two annually.

3. Call the HSCSN care manager to be your partner in getting enrollees in to get their immunizations in the recommended time frame.

Timeliness of Prenatal Care and of Postpartum Care 1. Schedule/provide initial prenatal care as soon as pregnancy is confirmed. 2. Remind expectant enrollees to make appointments for prenatal care and postpartum care 3. Educate enrollees about the importance of prenatal and postpartum care. 4. Contact HSCSN Care Management when enrollees cancel/fail to show up for scheduled

visits. 5. Alert HSCSN Care Management to any needs for outreach 6. Provide postpartum visits between 21 and 56 days after delivery 7. Global billing is a tool for your office to use for ease of billing purposes but you may submit

documentation of visits/care delivery by submitting the CPT II (Table 4) codes to document individual visits not captured in the global billing. Codes should be used with a zero charge as individual visit payments are already included in the global payment.

Table 4: Prenatal and Postpartum Care Codes

Description CPT Category II Initial Prenatal Care Visit 0500F Prenatal Flow Sheet Visit 0501F Subsequent Prenatal care Visit 0502F Postpartum Care 0503F

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CPT II Coding

CPT II Coding can be used to document care delivered in the office as well as results of procedures/test performed in the office. Use of these codes will help boost your Health Effectiveness Information Data Set (HEDIS) scores and decrease foot traffic to your office from reviewers coming in to try to obtain the information. The Measures have CPT codes attached and what they represent are: Table 1:

Description Comprehensive Diabetes Care CPT Category II

Most Recent HbA1c >9.0% 3046F Most Recent HbA1c <8.0% 3044F Most Recent HbA1c <7.0% 3044F Most recent LDL-C < 100 mg/dL 3048F Most recent LDL-C 100-129 mg/dL 3049F Most recent LDL-C ≥ 130mg/dL 3050F Positive Microalbuminuria 3060F Negative Microalbuminuria 3061F Positive Macroalbuminuria 3062F Documentation of treatment for nephropathy (e.g. Dialysis, ESRD, CRF, ARF, RI or visit to nephrologist)

3066F

Systolic Diastolic Most recent BP <130/80 mm Hg 3074F 3078F Most recent BP 130-139/80-89 mm Hg 3075F 3079F Most recent BP ≥140/90 mm Hg 3077F 3080F

Pregnancy Related Measures Initial Prenatal Care Visit 0500F Prenatal Flow Sheet Visit 0501F Subsequent Prenatal care Visit 0502F Postpartum Care 0503F

The utilization of coding to communicate care delivery is not limited to CPT codes either. Other results and counseling can also be documented through coding: Table 2: BMI for ages 17 and above

HCPCS ICD-9-CM Diagnosis G8417-G8420 V85.0-V85.5

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Table 3: BMI and counseling for ages 3-17

Description CPT ICD-9-CM Diagnosis HCPCS

BMI percentile V85.5 Counseling for nutrition

97802-97804

V65.3 G0270, G0271, S9449, S9452, S9470

Counseling for physical activity

V65.4 S9451

D. Satisfaction Surveys

Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) Included in HEDIS is the CAHPS® 5.0 survey, which measures enrollees' satisfaction with their care in areas such as claims processing, customer service, and getting needed care quickly. HSCSN annually conducts a CAHPS member satisfaction survey to ensure we are providing exceptional service to our enrollees and provide a vehicle to take enrollee feedback and utilize that information to make our organization better. In the past, HSCSN only conducted the Child and Child with Chronic Care Conditions survey, but in 2013, HSCSN began to conduct the Adult CAHPS survey as well. The survey contains a set composite of questions that are targeted towards the population we serve. We have also added plan specific questions and in the future, we will add new questions to the child survey around dental care, and cleanings, along with dental appointment timeliness. HSCSN utilizes a NCQA certified vendor to conduct the CAHPS survey. Provider Satisfaction Survey HSCSN annually conducts a Provider Satisfaction Survey to ensure we are providing exceptional service to our enrollees and provide a vehicle to take provider feedback and utilize it to make our organization better. HSCSN utilizes a NCQA certified vendor to conduct the Provider Satisfaction survey.

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E. Complaints Enrollees, caregivers, and providers have the right to express complaints about HSCSN services, benefits, staff and/or practices without prejudice and to obtain consideration and resolution to those Complaints. A Complaint is an expression of dissatisfaction about any matter other than an Action. A Complaint may be made in writing or orally with HSCSN. All complaints will be uniformly addressed in a prompt and fair manner. The process for resolving complaints involves the appropriate staff persons in addition to the person(s) about whom the complaint may apply. There are no penalties or punitive action for filing a complaint. All complaints will be resolved to the satisfaction of the complainant within 30 calendar days. Complaint resolutions are provided verbally to the complainant. If it is in the best interest of the enrollee/caregiver, HSCSN may extend the resolution timeframe up to 10 business days. If you are not satisfied with the resolution, you may file a grievance with HSCSN. Patterns of complaints registered over time will be analyzed to identify reoccurring issues and opportunities for improvement. Details involving the investigations and resolutions are kept confidential. All oral complaints, please call the Quality Inquiry Line at (202) 721-7168. Written complaints should be sent to:

Health Services for Children with Special Needs, Inc. Attention: Quality/Accreditation Department

1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

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F. Grievances It is HSCSN’s mission to provide quality care and service to our enrollees. It is the right of all enrollees to file a Grievance concerning HSCSN’s services and benefits without prejudice and to obtain consideration and resolution to those Grievances. A Grievance is defined as an expression of dissatisfaction about any matter other than an Action. An Action is defined as

- The denial or limited authorization of a requested service, including the type or level of service

- The reduction, suspension or termination of a previously authorized service or failure to renew or approve a current course of treatment

- The denial, in whole or in part, of payment for a service

- The failure of HSCSN to act within the timeframes for resolution and notification The term grievance also refers to the expression of dissatisfaction of a complaint resolution and is also used to refer to the overall system that includes Grievances and Appeals handled by HSCSN and access to the District’s Fair Hearing process.

1. It is the right of all HSCSN providers to file a grievance concerning HSCSN’s APPEAL decisions.

2. Providers also have the right to file a Grievance on behalf of an enrollee, WITH the enrollee’s written consent.

All Grievances shall be uniformly addressed in a timely and fair manner. HSCSN will not apply punitive action or penalties against an Enrollee, Provider or an Enrollee’s representative who files a Grievance or requests a Fair hearing. Enrollees shall be informed of their right to request a Fair Hearing with the Office of Administrative Hearings, District of Columbia Department of Health and Human Services, at any time in the Grievance process, and to obtain assistance in filing the Grievance from HSCSN’s personnel and the District’s Ombudsman. Enrollees are permitted to request a Fair Hearing without exhausting HSCSN’s internal Grievance process. A Grievance may be made in writing or orally with HSCSN; however an oral Grievance must be followed up with the request in writing within 10 days of the oral request, unless the Grievance was resolved. Upon receipt of a Grievance, a written acknowledgment letter will be sent to the individual filing the Grievance within two (2) business days. All Grievances shall be resolved within 30 calendar days from the date the Grievance was filed, unless an extension has been granted. An extension may be granted up to fourteen (14) calendar days if the Enrollee or the Provider acting on behalf of the Enrollee requests the extension or if HSCSN shows to the satisfaction of the DC DHCF) that there is a need for additional information and how the delay is in the Enrollee’s best interest. If an extension is granted, but was not requested by the Enrollee or the

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Enrollee’s representative, the Enrollee or the Enrollee’s representative shall be provided with written notice and the reason for delay. Upon resolution of a Grievance, a resolution letter will be sent to the individual filing the Grievance. If the Enrollee or the Enrollee’s representative is not satisfied with the resolution of the Grievance, they may request a hearing by HSCSN’s Internal Grievance and Appeals Committee, or request a Fair Hearing with the Office of Administrative Hearings, District of Columbia Department of Health and Human Services. All oral grievances, please call the Quality Inquiry Line at (202) 721-7168. Written grievances should be sent to:

Health Services for Children with Special Needs, Inc. Attention: Director, Risk Management

1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

G. Events (Sentinel, Critical, Never) and Unusual Incidents

Health Services for Children with Special Needs, Inc. (HSCSN) is committed to the promotion of safety in health care and ensuring a safe environment for our Enrollees. DHCF requires that all HSCSN Providers/Practitioners report any Critical/Sentinel/Never Event, Unusual Incident (UI) or PHI violations involving a HSCSN Enrollee to HSCSN within 24 hours of the incident. All reports should be reported on HSCSN’s Unusual Incident (UI) Report form and faxed to HSCSN’s Director of Risk Management at (202) 635-5591. You can also download a copy of the UI Report form on HSCSN’s website, under the Provider Services section. A Sentinel Event (as defined by The Joint Commission) is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The following are examples of a Sentinel Event:

- An unexpected death

- Serious physical injury or violent trauma resulting in admission

- Psychological injury (i.e. post-trauma stress syndrome, sexual exploitation)

- Suicide in inpatient setting or attempted suicide resulting in serious disability

- Rape/suspected sexual abuse on a patient

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- Patient death associated with a fall suffered in the hospital

- Patient death or serious disability associated with the use of restraints or bedrails

- Severe pressure ulcers acquired in the hospital

- Patient death or serious disability due to spinal manipulative therapy

- Patient death or serious disability associated with an electric shock

- Patient death or serious disability associated with a burn incurred in the hospital

- Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy

- Death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns

- Infant abduction or discharge to the wrong family

- Notification of and removal of a child or children by Child Protective Services

- Patient death or serious disability associated with patient disappearing for more than four hours

- Abduction of a patient

- Hemolytic transfusion reaction

- Patient death or serious disability associated with intravascular air embolism

- Patient death or serious disability associated with the onset of hypoglycemia, a drop in blood sugar

- Surgery on the wrong patient, wrong limb, or wrong body part or resulting in the loss of function

- Wrong surgical procedure performed on a patient

- Object left in a patient after surgery

- Death of a patient who had been generally healthy, during or immediately after surgery for a localized problem

- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics

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- Patient death or serious disability associated with a medication error

- Patient death or serious disability associated with the misuse or malfunction of a device;

- Any incident in which a line designated for oxygen or other gas to be delivered to a

patient contains the wrong gas or is contaminated by toxic substances

- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider

- Serious Public Health Issues, such as but not limited to:

- Non-compliant Tuberculosis patient with a history of HIV/AIDS and multi-resistant antibiotics

- Diagnosis of West Nile Disease

- Diagnosis of Lyme Disease

- Diagnosis of Lead Intoxication or Poison >fifteen (15) ug/dL

- Any other event or occurrence defined by DOH or DHCF as a Serious Public

Health Issue or Threat. A Critical Event (as defined by the DHCF) is a retrospective review of clinical quality of care issue(s) that has caused serious harm and/or injury upon investigation and meets the definition of a sentinel event. The following are examples of a Critical Event:

- Accidents of all types, e.g., those occurring in vehicles, homes, schools or community - Violent trauma - gunshot, stab wounds, etc. - Allegations of child abuse referred to the appropriate agency for investigation - Removal to Child Protective Services - Kidnapping - Serious untoward outcome experiences as a result of receiving health care services - Incidents of unnecessary force used by providers in rending care/therapy

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- Pharmaceutical errors that result in harm to the enrollees Never Event is (as defined by the National Quality Forum- NQF) are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility. Never events are also referred to as “serious reportable/adverse events.” A sentinel event may be included in the list of Never Events, however according to NQF (a nonprofit national coalition of physicians, hospitals, businesses and policy makers), a never event is an event that should never occur, despite human error in a health care facility. According to NQF, they have identified 28 Never Events that can be categorized into the following categories:

- Surgical Events - Product or Device Events - Patient Protection Events - Care Management Events - Environmental Events - Criminal Events

The following is a comprehensive list, complied by NQF, which describes mistakes that are serious and that should NEVER occur:

1. Surgery on the wrong body part 2. Surgery on the wrong patient 3. Wrong surgical procedure performed on a patient 4. Object left in patient after surgery 5. Death of a patient, who had generally healthy, during or immediately after surgery for

a localized problem 6. Patient death or serious disability associated with the use of contaminated drugs,

devices, or biologics 7. Patient death or serious disability associated with the misuse or malfunction of a

device 8. Patient death or serious disability associated with intravascular air embolism 9. Infant discharged to the wrong person 10. Patient death or serious disability associated with patient disappearing for more than

four hours 11. Patient suicide or attempted suicide resulting in serous disability 12. Patient death or serious disability associated with a medication error 13. Patient death or serious disability associated with transfusion of blood or blood

products of the wrong type 14. Maternal death or serious disability associated with labor or delivery in a low-risk

pregnancy 15. Patient death or serious disability associated with the onset of hypoglycemia, a drop

in blood sugar

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16. Death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns

17. Severe pressure ulcers acquired in the hospital 18. Patient death or serious disability due to spinal manipulative therapy 19. Patient death or serious disability associated with an electric shock 20. Any incident in which a line designated for oxygen or other gas to be delivered to a

patient contains the wrong gas or is contaminated by toxic substances 21. Patient death or serious disability associated with a burn incurred in the hospital 22. Patient death associated with a fall suffered in the hospital 23. Patient death or serious disability associated with the use of restraints or bedrails 24. Any instance of care ordered by or provided by someone impersonating a physician,

nurse, pharmacist, or other licensed health care provider 25. Abduction of a patient 26. Sexual assault on a patient 27. Death or significant injury of a patient or staff member resulting from a physical

assault in the hospital 28. Artificial insemination with the wrong donor sperm or egg

According to the District of Columbia’s Medical Malpractice Amendment Act of 2006, the District requires “that any licensed health care provider or medical facility must report adverse events, which include the 28 never events as defined by the NQF, plus one type of Hospital Acquired Infection (HAI), defined as central catheter associated laboratory confirmed primary bloodstream infections to the Department of Health biannually.” All reports should be submitted to the Department of Health in hardcopy or by facsimile, (202) 724-8677, using the standard Adverse Event Report Form. For a copy of the Adverse Event Reporting Form, go to http://doh.dc.gov/publication/dc-adverse-event-reporting-form. An Unusual Incident is an incident that does not meet safety standards or the standard of care or, routine operations of a provider that deviates from regular operations or established procedures and likely to lead to undesirable effects and the documentation thereof, synonym: occurrence report.

- Major Unusual Incident (MUI) - MUIs are serious incidents that pose a significant

danger, or that are likely to result or have resulted in serious consequences to the health and safety of the enrollee/individual.

- Minor Unusual Incident - Any event that is not consistent with the routine care of

enrollees or routine operations of the provider, or other significant events that otherwise deviate from regular routine operations or established procedures.

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Major Incidents* Code Incident Type

1 Alleged, suspected, or actual physical, verbal, mental or emotional abuse of enrollee 2 Significant, unexpected staff shortage 3 Mass Disturbances (i.e. riot) 4 Highly unusual incident posing immediate threat to life and safety (i.e., hostage taking, terrorist

threat, bomb, etc) 5 Operational breakdown that causes residential relocation of enrollees (i.e., telephone outage,

electrical blackout, natural disaster) 6 Alleged, suspected, actual criminal activity resulting in police involvement (ENROLLEE) 7 Alleged, suspected, actual criminal activity resulting in police involvement (PROVIDER) 8 Assault/altercation – Serious injury, enrollee to enrollee 9 Assault/altercation – Serious injury, enrollee to provider

10 Assault/altercation – Serious injury, provider to enrollee 11 Assault/altercation – Serious injury, enrollee to any other person 12 ALL Contraband (illegal drugs, alcohol, guns, knives, clubs, legally recognized items i.e.

fireworks)-Any provider, volunteer, or any other person who provides illegal drugs or alcohol to enrollees

13 Any unjust, improper or potentially criminal use of an enrollee or his/her resources for one’s profit, advantage or gratification

14 Fire resulting in serious injuries or of a suspicious nature 15 Serious injury – accidental, self-injurious, or of unknown origin to enrollee 16 Fall of enrollee and results in serious injury 17 Provider and Enrollee car accident resulting in serious injury to any person 18 Loss or theft to enrollee valued at $200 or more 19 Major property loss, theft or damage valued at $5000 or more which renders a facility unusable,

interferes with care of enrollee or results in an actual threat to health and safety 20 Any medical emergency requiring an enrollee receive emergency medical care (emergency room

or hospitalization) WHILE ENROLLEE IS ON THE PREMISES OF THE PROVIDER 21 Restraint of Seclusion – injury that requires first-aid or more resulting from, or happening while

in physical restraints or seclusion 22 Restraint or Seclusion – Use of 23 Restraint or Seclusion – Misuse of 24 Unauthorized Leave/Disappearance – Enrollees who are potentially dangerous, high profile or

notorious 25 Unauthorized Leave/Disappearance - Enrollees at serious risk due to disability or dangerousness

to self, after reasonable search or within 24 hours 26 Unauthorized Leave/ Disappearance – Enrollee who leaves a program or does not return as

scheduled, not located after reasonable search or within 24 hours 27 Unauthorized Leave/Disappearance – Children missing from an RTC without proper

authorization from the treating psychiatrist/psychologist or designee 28 Other

Minor Incidents* Code Incident Type

29 Alleged, suspected or actual criminal activity by enrollee that did not result in police involvement 30 Alleged, suspected or actual criminal activity by provider that did not result in police involvement 31 Assault/altercation – Minor or no injury – enrollee to enrollee

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32 Assault/ altercation – Minor or no injury – enrollee to staff 33 Assault/altercation – Minor or no injury – enrollee to any other person 34 Assault/altercation – Minor or no injury – Provider or any other person on provider’s premises 35 Fire resulting in minor or no injuries, not of a suspicious nature or no significant property damage 36 Minor injury to enrollee – accidental, self-injurious or of unknown origin 37 Enrollee fall with no injury or minor injury 38 Provider vehicle accident involving an enrollee with minor or no injury to any person 39 Loss or theft to enrollee valued at less than $200 40 Property loss, theft, damage valued at less than $5000 or damage to facility which results in

potential threat to health or safety 41 Suicide gesture – not life threatening (e.g. superficial scratches on the arm) 42 Other

*In accordance to the District of Columbia Department of Mental Health Policy on reporting Unusual Incidents. (See Appendix A – Forms)

H. Site Visits

The Quality/Accreditation department conducts provider site visits as part of the Quality and Performance Improvement Program. Site visits will also be conducted in response to an identified potential quality of care/service issue or in response to a complaint or grievance. Site visits may be announced or unannounced. The provider site visit monitors the facility management and conducts a medical record review. The provider site must have at least an aggregate score of 80 percent and must meet all required performance elements, regardless of the aggregate score. Providers will be scored on the following standards: Facility Management Environmental Care

- Access to Facility - Physical Appearance - Access to Care/Availability of Care - Clinical Services/Patient Education/Pharmaceutical & Vaccine/Laboratory Services - OSHA - Emergency /Safety/Infection Control - National Patient Safety Goals

Administration

- Policies & Procedures Human Resources

- Personnel Information Health Information Management

- Medical Record Management

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Medical Record Review Rights, Responsibility & Identification

- Patient Identification Plan of Care

- EPSDT & Physical Health Documentation - Behavioral/Mental Health Documentation - Clinical Documentation

HSCSN Provider Site Visit Policy, QM.04, states any review with a score less than 80 percent, or does not meet certain key must pass standards, requires a Corrective Action Plan (CAP). Providers who score less than 80 percent and/or do not meet the required standards will be given 10 business days after written notification of the survey results to submit a signed CAP. The following facility management and medical record review performance elements are must pass elements: Facility Management

Environmental Care

Access to Facility

Provisions for blind, hearing impaired &/or limited English proficiencies (LEP)

Access Ramp

Access to Care/Availability of Care

After hours/weekend access to physician information available & posted. Readily available via pager, mobile phone, answering service with directions to reach on-call personnel.

Clinical/Service/Patient Education /Pharmaceutical/Vaccine Management/Lab Service/OSHA

Evidence of translation services, such as, access to TDD/TTY

Each physician providing EPSDT services must have the necessary equipment

Practitioners who immunize must participation in the Vaccines for Children Program

Personal protective equipment (gloves, gown & mask) accessible/available

Emergency/Safety/Infection Control

At least one type of fire protection in place Emergency drugs/supplies/equipment available w/o obstruction

Airway, breathing, circulatory emergency management

National Patient Safety Goals

Comply with current CDC hand hygiene guidelines

Standardized abbreviations, acronyms and symbols including a list of abbreviations NOT to use

Identify a list of look-alike/sound-alike drugs and review the list annually.

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Administration

Policy & Procedure

Verifying Physician Licensure Personnel Policy

Supervision of Skilled/Unskilled Staff

Human Resources

Personnel Information

CPR Licensure Verification

Skills Checklist

Medical Record Review Plan of Care

Goals/Objectives are individualized & measurable

Plan of Care with licensed physician signature.

Comprehensive health (EPSDT) and developmental history, or update of medical and mental health status

To obtain a copy of standards utilized to conduct provider site visits please call the Quality and Accreditation Inquiry Line at (202) 721-7168.

I. Medical Record Documentation Documentation requirements are established for HSCSN providers to ensure that essential enrollee information is documented and consistent with accepted medical documentation standards of practice and comply with federal and state laws. HSCSN monitors provider compliance with appropriate procedures for maintenance of enrollee records for both active and inactive enrollees through periodic site visit reviews and medical record audits. There should be an established written protocol for medical records, which provides continuity, accuracy, and integrity of clinical data. Written entries into the medical record should be clearly legible and contain a factual account of care rendered. Primary Care Provider medical records will include: Patient Information

- Medical record shows that all pages contain patient’s name and a second identifier.

- Each clinical case record contains biological and demographic data that includes client’s name, address, date of birth, gender, or ethnic origin, next of kin, education, and the name or phone number of any legally authorized representative.

- All entries in the medical record must be signed with the name and professional status of

the individual who actually rendered the service.

- The medical record shows that all entries are timed and dated.

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- Medical record entries are legible and are maintained according to professional standards.

- Each medical record has a signed Notice of Privacy.

- Each medical record has a signed Release of Information.

- Medical record has a signed Informed Consent for Treatment, Care and Services. EPSDT and Physical Health Documentation

- Allergies or lack of allergies (NKA or NKDA) are noted and prominently displayed - Updated growth charts, if applicable

- The enrollee’s body mass index/body mass index percentile (BMI) is documented. - The enrollee has documented nutritional assessment, counseling or referral in the record.

- Hearing screenings are performed with results documented for each H&P (EPSDT) exam.

The objective or subjective screening is performed per periodicity schedule. - Vision screening performed with results documented for each H&P (EPSDT) exam. The

objective or subjective screening is performed per periodicity schedule. - Dental screening is documented at H&P (EPSDT) exam. Documentation of dental

assessment, referral and dental counseling is required.

- Comprehensive health and developmental history, or update of medical and mental health status

- Current medication(s) documented. - Current problem(s) documented. - Patient chief complaint is documented. - Diagnoses or medical impression is clearly documented. - Diagnostic studies ordered, including lead testing per EPSDT Periodicity Schedule. - PCP initials document review of diagnostic tests. - Documentation of objective and subjective findings of history and physical examination - Health and Developmental assessment (physical and mental) is completed

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- Health education/Anticipatory guidance, provided and documented which includes but is not limited to an assessment of: ⋅ Healthy and Safe Habits ⋅ Injury and Illness Prevention ⋅ Nutrition ⋅ Oral Health ⋅ Mental Health ⋅ Sexuality ⋅ Social Competence ⋅ ETOH & Substance Use ⋅ Violence & Abuse Prevention ⋅ Responsibility ⋅ School or Vocational Achievements ⋅ Family ⋅ Parental Health ⋅ Community ⋅ Physical Activity & Safety

- Immunization records which include a signed consent form and documentation that

includes enrollee name, date of birth, immunization given, dated administered, immunization site and lot number of the vaccine (in event of adverse reaction) or documentation of history of illness, evidence of antigen or seropositive test result.

- Enrollees’ referrals and referral outcomes are consistent with treatment needs in medical

record. - Requests for and results of consultations (file with PCP initials). If a consultation is

requested for an enrollee, there must be an entry in the chart from the consultant outlining objective findings, assessment, and treatment plan.

- The enrollee’s medical records indicated that disposition; recommendations and

instructions are coordinated and prepared. - Laboratory and other studies as appropriate initialed by the PCP. Each medical record

should have a section for laboratory reports. All entries in the section should have the primary physician’s initials or signature to verify review before filing in the medical record. Abnormal reports should show evidence of attempt at follow-up as indicated. All reports should be chronologically sequenced.

- When patients are seen in the emergency room, appropriate coordination of services is

done with PCP follow-up.

- When patients are admitted to inpatient services, discharge summaries are present and medical follow-ups are documented.

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Behavioral/Mental Health Documentation

- Each patient should have an Axial Diagnosis with medical history in the record to be identified with diagnosis applicable to medical condition.

- An initial psychiatric assessment is performed on each patient by a licensed independent

practitioner, within 60 hours of admission into inpatient crisis stabilization programs and within one week after admission to residential programs and settings (this time frame, applies to weekend and holiday admissions as well as to weekdays) to clearly state reasons for treatment. Some situations may occur in which medical needs require completion of a physical assessment within a shorter timeframe.

- Organizations providing non 24 hour care services (such as partial hospitalization, day

treatment, outpatient, intensive outpatient services, supportive living, case management, assertive community treatment, adult day care or emergency shelters) have written procedures addressing physical health screenings.

- The provider defines in writing the data and information gathered during initial screenings,

emotional, and behavioral assessments to include but not limited to the following:

⋅ History of emotional problems ⋅ History of behavioral problems ⋅ Addictive behaviors as a primary or co-occurring conditions including the use of

alcohol, other drugs, gambling, or other addictive behaviors by the client and family members

⋅ Current mental and behavioral functioning ⋅ Maladaptive or problem behaviors ⋅ Community resource accessed by the client

- When indicated, the following evaluations are conducted:

⋅ Mental status ⋅ Psychiatric ⋅ Psychological ⋅ Language, self care, visual-motor, and cognitive functioning

- The record must contain a current psychiatric evaluation of the patient (annually), and the

information defined by the provider to gather during the psychiatric evaluation includes at least the following:

⋅ History and Physical ⋅ Past Psychiatric Treatment Information ⋅ Current Medications (Past Medical History & Developmental History) ⋅ Social History (School, Family, Substance Abuse, Family Medical and Psychiatric

History, Child History, and Medical Screening Exam)

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- Dynamic Formulation (bio-psychosocial model) - Diagnostic Impressions (5 axis diagnosis) - Initial Treatment Plan - Problem List - Therapist Progress Notes - Psychotherapy Initiation Form - Composition of Medical Records - Physician Encounter Form Guidelines - Problem Addressed

o All additional assessments are performed by a licensed independent practitioner,

who is qualified and competent to do so, within 24 hours of admission to inpatient or crisis

o Stabilization programs and within one week after admission to residential programs and settings (this timeframe applies to weekend and holiday admissions as well as weekdays). Some situations may occur in which the medical need require completion of a physical health assessment within a shorter time frame. If a comprehensive medical history and physical examination have been completed by a licensed independent contractor within 30 days prior to admission to the organization, a durable legible copy of this report may be used in the clinical/case record as the physical health assessment, but any changes to the client’s condition since the history and physical must be recorded at the time of admission.

- The record must contain a current psychosocial assessment in the record of the patient

(every two years) and the information defined by the provider to be gathered during the psycho-social assessments includes conflicts or problems involving at least one of the following:

⋅ Environmental and Living Situation

⋅ Leisure and Recreation

⋅ Religion and Spiritual Orientation

⋅ Childhood History

⋅ Military Service History, if applicable

⋅ Financial Issues

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⋅ Usual Social, Peer Groups, and Environmental Setting

⋅ Sexual History

⋅ Family Circumstances

⋅ Psychotherapy Initiation Form

- Suicide Risk Assessment must be documented

- A nutritional screening is done, and when indicated, an in-depth nutritional assessment is performed or referred for assessment.

- A vocational screening is done and when indicated, an in-depth vocational assessment is

performed or referred for assessment. When conducted by the provider, the information to be gathered during initial vocational assessment includes at least the following:

⋅ Current Work Skills and the potential for improving skills or developing new ones

Educational background ⋅ Amenability to Vocational Counseling

⋅ Aptitudes, interests, and motivations toward involvement in various job-related

activities

⋅ Physical Abilities ⋅ Cognitive Abilities

⋅ Skills and Experiences in seeking jobs

- An educational status screening and Individualized Education Plan is done, and when

indicated, an in-depth educational status assessment is performed or referred for assessment. The record must contain a current individual education plan in the record of the patient (yearly updates). A screening identifies clients for whom a more in-depth educational assessment is indicated. Those identified clients are either assessed or referred for assessment. The information defined by the provider to be assessed during initial educational assessment includes, as relevant to the care, treatment, and services, at least the following:

⋅ The Clients Educational Background ⋅ Preferences of Areas of Study and Academic Performance

⋅ Attitude toward Academic Achievements

⋅ Possibilities for Future Education

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- Planning includes creating an initial plan of care [Individualized (Master) Treatment Plan (ITP)] or services appropriate to the patient’s specific assessed needs and then revising or maintaining the plan based on patient’s response. The plan must be formulated within 30 days of the patient admission into the program and performed by a qualified individual. The preliminary plan of care, treatment and services include the following:

⋅ Measurable goals and objectives based on assessed needs, strengths, and the client’s

limitation.

⋅ Dates to achieve goals ⋅ Needs are identified based on information from the assessment.

⋅ Care, treatment, and service decisions are collaborative and interdisciplinary when

more than one discipline is involved in the patient’s care, treatment and services.

⋅ Planning care, treatment, services includes identifying specific objectives for the identified goals.

⋅ Planning care, treatment, services include interventions and services necessary to

meet identified goals.

- The provider develops a plan of care, treatment, and services that reflect the assessed needs, strengths, and limitations of the patient.

- The plan of care, treatment, and services include the following:

⋅ Clearly defined problems and needs statements ⋅ Measurable goals and objectives based on the assessed needs, strengths, and patient’s

limitations

⋅ Frequency of care, treatment, services and expected outcomes

⋅ Description of facilitating factors and possible barriers to care, treatment, services or reaching goals.

⋅ Appropriate to the services or setting, the criteria for the transition to more

independent and less restrictive environments and successful adaptation into community settings.

Objectives are as follows:

⋅ Sufficiently specific to evaluate the client’s progress ⋅ Expressed in behavioral terms that specify measurable indices of progress

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- Goals and objectives are re-evaluated, and when necessary, revised based on changes in the client’s problems, needs, and responses to care, Treatment, services or, if no changes occur, at a minimum specified time interval established by provider policy.

- The ITP must contain a concise discharge criterion that reflects measurable goals and

objectives based on the assessed needs, strengths, and the client’s limitation.

- Client-Specific information is readily accessible to those involved in the Medication Management System. If treatment modality is Medication Management, the record contains:

⋅ Current medication list with changes, doses, and administration times ⋅ Baseline blood levels/follow-up blood levels (as appropriate) ⋅ Baseline vital signs with follow-up as appropriate to medications

⋅ Abnormal Involuntary Movement Scale (AIMS) testing every six (6) months (when

appropriate)

⋅ Response to medications are noted

- The provider’s record contains documentation of physical holds, seclusion and restraints and evidence that incidents have been reported to HSCSN:

⋅ Behavior necessitating the intervention ⋅ Documentation noting that non-physical interventions would not be effective ⋅ Behavioral response during the intervention ⋅ Documentation of post intervention assessment ⋅ Date and time intervention is discontinued ⋅ Documentation of time length of the intervention, for each type utilized

- Patient/Client may be discharged from the provider entirely, discharged or transferred to

another level of care, treatment, and services, to different professionals, or to setting for continued services. The providers’ processes for transfer or discharge are based on the client’s assessed needs. To facilitate discharge or transfer, the provider assesses, and helps to ensure that continuity of care treatment, and services is maintained. The provider must do the following:

Send a discharge summary to PCP and HSCSN within 30 days of discharge to include: o The enrollee’s need for continuing care to meet physical, behavioral and

psychosocial needs. o Procedures performed and the care, treatment and services provided o Discharge planning or transfers are discussed with enrollee in a timely manner. o The enrollee and family involvement in the planning of transfer or discharge.

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o The enrollee receiving information on the reason why he/she is being transferred. o The discharge planning process initiated early in care, treatment, and services.

Sample Medical Chart Order The medical record is a legal document. An individual at each provider’s office or facility should be designated to coordinate the medical record system in order to maintain the unique identification of each patient/enrollee’s record, ensure confidentiality, access to the records and monitor the release of information, and maintain organization of the files.

Medical Database

Demographics, biographical/personal data, past medical history/family history, assessment of tobacco, alcohol, and substance abuse.

Health Coordination

Problem list/medical diagnoses, medication list, allergies and adverse reactions to drugs, immunization records

Medical Encounters

History and physical examinations, treatment record/plan of action, physician orders, prescribed medications, diagnostic tests, medical instructions, progress notes

Diagnostics Laboratory reports, radiology reports Consultations Consultation reports, follow-up documentation

EPSDT EPSDT Reports Referrals Authorization, copy of referrals

Correspondence Letter, miscellaneous information

J. Access to Provider Records Upon reasonable request and in accordance with applicable confidentiality privacy laws, representatives of HSCSN, the Commissioner of Insurance and Securities or an authorized designee, Department of Health Care Finance, DC Medicaid Fraud Control Unit, United States Department of Health and Human Services, Comptroller General of the United States, Federal Bureau of Investigation, U.S. General Accounting Office, or their authorized representatives (collectively “Inspectors”) may inspect, during regular business hours, books and records customarily maintained by Provider including medical and financial records relating to HSCSN enrollees.

- Provider agrees to provide access to provider records relating to HSCSN enrollees within 30 days of written notice to the Provider. Failure to provide access within 30 days of written notice may result in denial of claims.

- The Inspectors may also inspect other books and records customarily maintained by Provider as necessary for the purposes of verifying claims, coordinating benefits, or reviewing appropriate utilization of services, included but not limited to issues of quality of care services.

- The Inspectors may inspect the affairs of Provider, including onsite inspections and periodic medical audits, as reasonably necessary for the protection of the Department of

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Health Care Finance’s interests and HSCSN enrollees and to otherwise evaluate (including periodic testing) the services being performed.

- Notwithstanding the foregoing, all requests for information shall be subject to applicable confidentiality laws Provider shall provide HSCSN, free of charge, copies of medical records requested by HSCSN for claims payment determination, utilization review, quality assurance, HEDIS audits or matters involving potential fraud, waste, or abuse. K. Access to Enrollee Records I. Permitted Uses and Disclosures:

HSCSN may request Protected Health Information (PHI) for: a. Treatment, payment or health care operations, b. The health care operations of another covered entity or health care provider, if

each entity has or had a relationship with the individual who is the subject of the PHI being requested, and the disclosure is:

i. For a purpose listed in the definition of health care operations; or ii. For the purposes of health care fraud and abuse detection or

compliance. c. Another covered entity that participates in an organized health care

arrangement with The HSC Health Care System for any health care operation activities of the organized health care arrangement.

d. Treatment: The provision, coordination, or management of health care and

related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a member; or for the referral of a member for health care from one health care provider to another.

e. Payment: Any activities undertaken either by a health plan or by a health care

provider to obtain premiums or to determine or fulfill its responsibility for coverage and the provision of benefits under the health plan or to obtain or provide reimbursement for the provision of health care.

f. Health Care Operations: Any one of the following activities to the extent the

activities are related to providing health care:

i. Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting health care providers and members with information about treatment alternatives, and related functions that do not involve treatment;

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ii. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals, accreditation, certification, licensing, or credentialing activities;

iii. Conducting or arranging for medical reviews, legal services, and auditing functions, including fraud and abuse detection and compliance programs;

g. Indirect Treatment Relationship: A relationship between an individual and

a health care provider in which the health care provider delivers health care to the individual based on the orders of another health care provider; and the health care provider typically provides services or products, or reports the diagnosis or results associated with the health care, directly to another health care provider, who provides the services or products or reports to the individual.

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V. Regulatory Standards

A. Corporate Compliance Program HSCSN administers a comprehensive Corporate Compliance Program consistent with District of Columbia and federal laws and regulations. The purpose of the program, at the direction of the Chief Compliance Officer, is to detect, investigate, prevent and/or sanction incidents of waste, fraud and abuse on the part of staff, members, Providers and subcontractors. The Corporate Compliance Program is a vehicle that enables HSCSN to prevent, detect, and resolve situations or conduct that does not adhere to applicable laws and The HSC Health Care System’s Code of Conducts and business policies. The Corporate Compliance Program activities include:

- Training and Education. - Fraud, Waste & Abuse prevention, detection, and investigations. - Preserving Member Rights concerning Privacy and Confidentiality. - Ongoing monitoring of quality health care services. - Oversight and ongoing monitoring of delegated responsibilities of HSCSN’s

provider network. As a contracted provider with HSCSN, you are obligated under 42 C.F.R. §1001.1901(b), to screen all employees, contractors, and/or subcontractors in your practice/ facility to determine whether any of them have been excluded from participation in Federal health care programs. You can search the HHS-OIG website, at no cost, by the names of any individuals or entities. The database is called LEIE, and can be accessed at www.oig.hhs.gov/fraud/exclusions.asp. Providers and their staff shall cooperate fully in Compliance and FWA investigations and be available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials or in any other judicial process, as necessary.

B. Fraud, Waste and Abuse (FWA) 1. Background

Under the CASSIP contract, HSCSN receives state and federal funding for payment of services provided to our enrollees. By accepting claim payments from HSCSN, health care providers are receiving District and federal program funds, and are therefore subject to all applicable federal and /or District laws and regulations relating to this program. Violations of these laws and regulations may be considered Fraud or abuse against the District of Columbia Department of Health, Department of Health Care Finance. Provider contracts require that all providers adopt and implement a compliance plan that adheres to the principles set forth in the applicable Compliance Program Guidance published by the Department of Health and Human Services Office of Inspector General (HHS OIG) and is commensurate with the Provider’s size. Providers shall comply with HSCSN’s policies regarding the False Claims Act (“FCA”) established under sections 3729 through 3733 of title 31, United

Regulatory Standards

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States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, as well as HSCSN’s policies regarding detecting and preventing fraud, waste, and abuse in Federal health care programs (as defined in section 1128B(f) of the Social Security Act). Provider shall obtain a copy of such policies by downloading them from HSCSN’s website at www.hscsn-net.org/provider_services. 2. What is your role concerning the FCA? You are essential to your organization’s compliance with the FCA.

- The codes your office/facility attaches to diagnoses and procedures, the documentation you keep for each patient, the bills you file –even the dates you record when procedures occur are subject to the FCA. Therefore, your work must be clear, accurate and in compliance with all rules and regulations.

Safeguard your organization by ensuring: - You document orders in the patient’s medical record; - Services are deemed medically necessary based on patient’s needs; - Medical necessity is documented in the patient’s medical record; - All billing, coding, and reimbursement rules are followed; - Services not rendered, are credited to the patient’s account; - Accountability for your actions and acting with integrity in all circumstances. - You do not retain Medicaid funds that were improperly paid

3. Fraud, Waste and Abuse

Fraud - means an intentional deception or misrepresentation by a person with the knowledge that the deception could result in some unauthorized benefit to himself or to some other person. It includes any act that constitutes fraud under applicable Federal or State law.

Waste - means the over-utilization of services not caused by criminally negligent actions;

waste involves the misuse of resources.

Abuse - means provider practices that are inconsistent with sound fiscal, business, or medical practices, and that result in an unnecessary cost to the Medicaid program, or in reimbursement for services medically unnecessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program

Examples of Fraud, Waste and Abuse: The following list provides examples of fraud, waste and abuse. The list is intended for informational purposes and does not purport to represent the universe of actions which may be construed as fraud, waste and/or abuse.

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C. Audit and Oversight Activity

One of the elements in an effective Compliance Program is auditing and monitoring. To ensure that all HSCSN Enrollees receive appropriate health care services, the Compliance Department performs periodic audit of contract responsibilities and services provided by the HSCSN Provider Network. The objective of auditing and monitoring activities is to ensure that HSCSN fulfills its responsibility to identify and recover inaccurate payments which may be a result of inadvertent or intentional provider actions or misrepresentations. HSCSN reserves the right to conduct claim audits and reviews to ensure compliance with standard coding, billing, medical record documentation guidelines and appropriate reimbursement

The areas that will be reviewed include, but are not limited to, the following:

• Billing for services that were not provided • Intentional misrepresentation • Billing services at a higher level than which was rendered • Failure to comply with the Provider Agreement, HSCSN policies and procedures, and/or

other relevant guidelines, regulations or laws

Falsifying Claims/ Encounters Alteration of a Claim Upcoding Incorrect Coding Double Billing Unbundling Billing for Services/ Supplies not Provided Misrepresentation of Services Substitution of Services Submission of Any False Documents

Abuse of a Member Physical Abuse Neglect Mental Abuse Emotional Abuse Discrimination Providing Substandard Care

Administrative / Financial Kickbacks/Stark Violations Fraudulent Credentials Fraudulent Enrollment Practices Fraudulent Recoupment Practices Embezzlement

Member Fraud Eligibility Determination Issues: Resource Misrepresentation (Transfer/Hiding) Residency / Citizenship Status Household Composition Income Misrepresentation of Medical Condition

Delivery of Services Denying and/or Limiting Access to Services/Benefits Failure to Refer to a Needed Specialist Under and/or Over Utilization

129

• Inadequate documentation to support the services billed • The deliberate performance of unwarranted or medically unnecessary services for the

purpose of financial gain

D. Provider Responsibilities Fraud and Abuse Involving Members If you have information about potential fraud, waste and/or abuse that is committed by a member or someone claiming to be a member, please notify either the HSCSN Compliance Officer or the Department of Health Care Finance using the contact information listed below. Fraud and Abuse Involving Health Professionals If you have information about potential fraud, waste and/or abuse that is committed by another health professional or his/her staff, such as inappropriate billing or delivery of services, please notify either the HSCSN Compliance Officer or Department of Health Care Finance using the contact information listed below. Reporting Fraud and Abuse To report member and provider fraud, waste and/or abuse, please forward information to the following:

HSCSN Corporate Compliance Hotline: (202) 454-1223

OR

HSCSN Attn: Chief Compliance Officer

1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

OR

The Department of Health, Department of Health Care Finance, Office of the Investigation &

Compliance Fraud, Abuse and Waste Hotline: 1-877-632-2873 OR

District of Columbia Medicaid Fraud

Control Unit for Investigation Office of Inspector General hotline.oig@dc.gov

1-800-521-1639

130

All information provided to HSCSN regarding a potential fraud and abuse occurrence is maintained in the strictest confidence and in accordance with the terms and conditions of HSCSN Compliance Program policies and procedures and applicable law. Any information developed, obtained or shared among participants in an investigation of a potential fraud and abuse occurrence is maintained specifically for this purpose and no other. HSCSN is committed to maintaining high ethical standards as reflected in our Code of Conduct. Concerns regarding HSCSN’s adherence to our Code of Conduct should be reported to the Chief Compliance Officer as directed above.

131

Appendix A – Forms

Appendix A

Provider Interest Form

Thank you for your interest in joining the HSCSN network. Please complete this form in order to begin the first step towards the credentialing process. This is not an application. If you do not currently have a CAQH ID, we will obtain one for you. Once you have received your CAQH ID, please visit https://upd.caqh.org/oas to complete the CAQH application.

Last Name _________________________First Name _______________________

Middle ____________________________

Group Practice _________________________________________________________

Practice Address ________________________________________________________

City _______________________________________ State ______________________

Zip Code ____________

Telephone ________________________ Email _______________________________

DOB: _______________________ SS#: ___________________________

CAQH ID # __________________________

Specialty (1) _______________________ Specialty (2) _____________________

Degree Type________________

Groups Contracted with HSCSN Prospective Contracts with HSCSN Send request to tdesta@hscsn.org or fax (202) 480-2333 Attn: Tirsit Desta

Send request to jford@hscsn.org or fax (202) 480-2333 Attn: Jackie Ford

133

SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All title XX providers must complete Part II (a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III.

INSTRUCTION FOR COMPLETING DISCLOSURE OF OWNERSHIP AND

CONTROL INTEREST STATEMENT (DC-1513)

Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by Titles V, XVIII, XIX, AND XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the District of Columbia state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the D.C. State Agency to enter into an agreement or contract with any such institution or in termination of existing agreements.

General Instructions For definitions, procedures and requirements refer to the appropriate Regulations: Title V -42CFR 51a.144 Title XVIII -42CFR 420.200-206 Title XIX -42CFR 455.100-106 Title XX -45CFR 228.72-73 Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks Section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet.

Return the original copy to the State agency: retain the photocopy for your files.

DETAILED INSTRUCTIONS These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory.

IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I – Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item II- Self-explanatory Item III- List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program. Indirect ownership interest is defined, as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity .The amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be

reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A’s interest equates to an 8 percent indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity, which may be maintained, by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e. joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV-VII- Changes in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the ownership partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation or any change of ownership. For Items IV-VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Item IV- (a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate that date in the appropriate space. Item V- If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI- If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate.

DISCLOSURE OF OWNERSHIP Directions: Follow the instructions found in this section to complete the document on the next page. Remember to sign the document.

134

Item VII- A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates. Item VIII -If yes, list the actual number of beds in the facility now and the previous number

135

DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT

Identifying Information (a). Name of Entity D/B/A Medicaid Provider No. NPI Number. Telephone No.

Street Address City, County, State Zip Code

II. Answer the following questions by checking “Yes” or “No”. If any of the questions are answered “Yes”, list names and addresses of individuals or corporations under Remarks on page 2. Identify each item number to be continued.

A. Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVII, XIX, or XX?

�Yes � No

B. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVII, XIX, or XX?

� Yes � No C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity

who were employed by the institution’s organizations, or agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVII providers only) � Yes � No

III. (a.) List names, addresses for individuals, or the EIN for organization having direct or indirect ownership or a controlling interest in the entity. (See

instructions for definition of ownership and controlling interest.) List any additional names and addresses under “Remarks” on Page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks.

Name Address EIN

(b) Type of Entity: � Sole Proprietorship � Partnership � Corporation � Unincorporated Associations � Other (Specify) (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks.

Check appropriate box for each of the following questions (d) Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. � Yes � No

Name Address Provider Number

136

IV. (a). Has there been a change in ownership or control within the last year?

� Yes � No If yes, give date ____________________

(b) Do you anticipate any change of ownership or control within the year? � Yes � No

If yes, when? ______________________

(c) Do you anticipate filing for bankruptcy within the year? � Yes � No

If yes, when ______________________

(d)Is this facility operated by a management company, or leased in whole or part by another organization? � Yes � No

If yes, give date of change in operations _______________________________

V. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN) � Yes � No

Name EIN# Address

WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE D. C. STATE AGENCY AS APPROPRIATE.

Name of Authorized Representative Title

Signature Date

HSCSN BEHAVIORAL HEALTH HOME SERVICES REFERRAL FORM Initial Request Change in Request

I. PATIENT INFORMATION Member Name: M F Date of Referral: Member ID: Date of Birth: Age: School/Grade: Current Behavioral Health Provider_____________________________________________________________________ Contact Information (phone number & email)____________________________________________________________ Provider Type (School-based, Community Based, etc.)____________________________________________________ *NOTE: An in-home assessment will be performed by an independent licensed behavioral health professional, identified by HSCSN, who will determine whether the enrollee meets medical necessity criteria for home-based services. Upon approval, HSCSN will conduct ongoing review of home care services and effectiveness for medical necessity and appropriateness. II. REASON FOR REFERRAL/PRESENTING PROBLEM Indicate the specific concern(s) which may impact enrollee’s health and/or recovery. III. PERTINENT HEALTH HISTORY – To be completed by referring provider (Licensed health professional) DSM-IV Diagnosis:

AXIS I: AXIS II: AXIS III: AXIS IV: AXIS V: Medications: Therapies: Hospitalizations: y /n Hospitalization for Suicidal Ideation/Attempts: y / n Residential Treatment: y / n (where yes is indicated, please give details) Family Functional History: History of Substance Abuse:

Lives with: Parent Relative Foster Parent Group Lives Alone Other (please specify)________________ Legal Status: Probation Juvenile Justice Foster Care Protective Services History of Abuse: Verbal Sexual Physical Emotional Abuse IV. OTHER PERTINENT INFORMATION (Check all that apply) Behavioral Symptoms

Aggression

Emotional Instability

Extreme Impulsivity

Severe Agitation

Non-Compliant Behavior

Medication Compliance

Outpatient Treatment Compliance Cognitive Limitations

Mild Mod Severe

Intellectual or Dev. Disability

Physical Health Limitations

Please specify __________________________________ Caregiver Limitations

Cognitive Social Physical

Activities of Daily Living (with or without cueing): Bathing: (Check one) I

M

D

Social I

M

D

Grooming: (Check one) I M D Emotional I M D Dressing: (Check one) I M D Attention I M D Eating: (Check one) I M D Safety/Judgment I M D Mobility-Ambulation I M D Incontinence > 3 yo Y N

I = independent (able to do on their own w/very minimal assistance) M = moderate dependence (needs minimal to moderate assistance) D = dependent (cannot perform on their own without maximal assistance)

PROVIDER NAME: Please Print Signature/ Date: Phone Number:

HSCSN Home Care Referral Form

Initial Request Change in Request

Instructions: Please complete the information and fax to HSCSN at 202-721-7190

I. PATIENT INFORMATION Member Name: Sex: M F

Member ID: Date of Birth: Height: Weight:

Primary Diagnosis : Treating Diagnosis/ICD 9 Code for Home Care: II. HOME CARE ORDER – to be completed by a MD or NP

Visit for Assessment and Recommendations

PT OT ST RN SW

_____________________________________________________________ _____________________________________________________________

Skilled Nurse Hours/Day ____________________#of Days/Wk____________________ _________ Dates of Service: ________________ to _______

To: __________________________________________________________

_____________________________________________________________

_____________________________________________________________

PCA/ HHA Hours/Day ____________________#of Days/Wk____________________ Dates of Service: ________________ to ________________ To: __________________________________________________________

III. CERTIFICATE of MEDICAL NECESSITY (Check all that apply) – to be completed by MD or NP

Respiratory/Cardiac Status

Ventilator: Yes No O2 Route______ Pulse ox Apnea Monitor Suctioning Oral_____ Deep ____ Trach Aspiration/Reflux precautions Other ________________________

________________________

Nutrition Tube Feeding G-tube___ J-tube___

____ Continuous Day___ Overnight Bolus - frequency________

Elimination/Skin Care

Ostomy care - Freq ________ ________

Wound care - FreqCatheterization - Freq ______

Medication Regime Complex Meds >every 8hrs per day or

includes (IV, SubQ, or Nebulizations)

Neurological Paralysis; type _____________ Spasticity

Cognitive Mild Mod Severe Intellectual or Dev. Disability Other

Caregiver limitations (Cognitive/social/physical)

Specify________________________

________________________

Activities of Daily Living (with or without cueing): Bathing: (Check one) I

M M

M D D

D

Safety/Judgment

Emotional

Incontinence > 3 yo

Social I

M

D D D D

Grooming: (Check one) I I MDressing: (Check one) I M Attention I M Eating: (Check one) I D I MMobility-Ambulation I M D Y N

I= independent (able to do it on their own w/very minimal assistance) M=moderate dependence (needs minimal to moderate assistance) D=dependent (cannot perform on their own without maximal assistance)

Other pertinent clinical information: PROVIDER NAME (MD or NP): Please Print Phone Number:

Signature/ Date:

HSCSN Home Care Order Instructions: Please complete the information and fax to HSCSN at 202-721-7190

I. PATIENT INFORMATION Enrollee Name: Sex: M F

Enrollee ID: Date of Birth:

Height: Weight:

Primary Diagnosis : Treating Diagnosis/ICD 9 Code for Home Care: Date of RN Assessment:___________________ Initial 6 Month Reassessment II. RECOMMENDATIONS (RN Assessment Attached)

PCA Hours/day ____________________ # Days/Wk____________________

Dates of Service: ________________ to ________________

Additional evauluation(s)/service(s) recommended based on RN assessment of enrollee: PT ___________________ OT _____________________ ST ______________ SW

_______________________________________________

Behavioral Health Home Services _______________________ If you wish to discuss the Personal Care Aide or other recommendations, please call 202-467-2737 to speak with a Physician Reviewer. PROVIDER NAME (MD or NP): Print

Signature/ Date:

Phone Number:

HSCSN Personal Care Aide (PCA) Referral Form Please complete the information and fax to HSCSN at 202-721-7190

I. MEMBER INFORMATION Member Name: Sex: M F Ht Wt Member ID: Date of Birth: Primary Diagnosis : Treating Diagnosis/ICD 9 Code for Home Care: II. OTHER PERTINENT CLINICAL INFORMATION

III. REQUESTING PROVIDER INFORMATION (MD or NP): Please Print Provider Name Phone Address City State ZIP Provider Signature Date IV. REASON FOR REFERRAL HSCSN requires an initial and periodic assessment of the enrollee by a Home Health RN to determine personal care aide needs in the home. Based on Medicaid regulations and medical necessity requirements, the enrollee must have a documented need for home care; services cannot be authorized for convenience or babysitting. Upon receipt and review of the completed Home Health RN assessment, the HSCSN Home Health nursing staff will send the RN assessment to the treating provider with an order indicating the level of care, number of hours and schedule, as determined by the assessment. The treating provider will review, sign and date the order with modifications as needed. Indicate the service(s) being requested:

Personal Care Aide (PCA)- services not related to a behavioral health condition provided by non-licensed staff to assist with basic personal care services, includingbathing, grooming, toileting, feeding, and mobility If enrollee requires assistance related to his/her behavioral health needs please complete the BH Home Services Form. Comments:_____________________________________________________________________________

Occupational Therapy Physical Therapy Speech Therapy Social Work Comments:_____________________________________________________________________________ This referral form does not guarantee approval for PCA services. The Physician will be sent the outcome of the RN assessment and recommendations by fax, within 72 hours of completion of the assessment. Please contact the HSCSN UM Department 202-467-2737 if you have any questions about the referral or form.

HSCSN Utilization Management Department Personal Care Aide (PCA) Assessment Form Type of Assessment: Initial □ Re-Assessment □ Address: _____________________________________________ _____________________________________________ Will the PCA service be provided at this location? Yes □ No □ If no, where will service be provided? □School □ Residence (not primary) Address: _____________________________________________ _____________________________________________ Primary Caregiver: □ Enrollee □ Parent(s) □ Sibling □ Foster Parent □ Other: ________________ Diagnosis and ICD-9-CM Codes - List each medical diagnosis and ICD-9-CM code. (Diagnosis to be obtained from the referral form)

Diagnosis ICD-9-CM code Comments

Medications

Current Medications Dose/Frequency/Route Comments

How are medications given? Check one below

Without Assistance Administered/Monitored by family member Administered/Monitored by professional nursing staff

FOR 18y and older only. Is the enrollee independent in the following activities?

Independent Activities of Daily Living Yes No Meal Preparation

Using the phone Shopping Home Maintenance

Directing Care Determination - Enrollees must be able to direct their own care or have a responsible party that provides the support needed to direct the PCA care. Yes □

□

□□

No □ □ □ □

Can enrollee identify their own needs? Yes No Can enrollee direct and evaluate PCA task accomplishments? Yes No Can enrollee provide and/or arrange for their health and safety? Yes No Primary caregiver is required and present for assessment? Name: _________________________________________ Individual(s) present for Evaluation: □□

Enrollee □ Parent(s) □ Sibling □ Foster Parent Other: ________________________________________

Does the primary caregiver have a condition that impacts their ability to provide care for the enrollee being assessed (medical, physical, or mental health)? Yes □ No □ If yes, what is the impairment? (Caregiver to provide documentation) Are there any problems where you currently reside? Check all that apply Yes No Describe Problem Barriers to access Electrical hazards Fire Hazards/No smoke alarm Insufficient Heat/Air conditioning Insufficient hot water/water Poor toilet facilities Defective stove, refrigerator, freezer Defective washer/dryer Poor bathing facilities Structural problems Telephone not accessible Unsafe neighborhood Unsafe/poor lighting Unsanitary conditions Other:

Special Medical Procedures: Does the enrollee receive any special nursing care?

Site, Frequency, Duration Yes No Bowel/Bladder Training Dialysis Dressing/Wound Care Respiratory Treatment Eye care Glucose/Blood Sugar Testing Oxygen Radiation/Chemotherapy Restraints (Physical/Chemical) ROM Exercise Trach Care/Suctioning Ventilator Other:

Sensory Functions Does the enrollee have problems with vision, hearing and/or speech?

No Impairment Impairment Complete Loss Compensation No Compensation

Vision Hearing Speech

Activities of Daily – A dependency in an ADL is defined as a daily need for one or both of the following:

1. Cuing and constant supervision to complete the task OR 2. Hands-on assistance to complete the task.

Activity Y N Description of assistance needed O R Dressing

Grooming/Hygiene

Bathing

Eating

Transfers

Mobility

Positioning

Toileting

O=Observed R=Reported

Behaviors Y N Increased vulnerability due to cognitive deficits or socially inappropriate behavior; or resistive to care, verbal aggression; or physical aggression towards self, others; or destruction of property

If “Yes”, describe the behavior(s) of the enrollee, including the frequency and the intervention(s) needed below. If “Yes”, Behavioral Health Home Assessment should be considered.

Indicate day(s) and time(s) services are required M- (6a-12n) A- (12n-6p) E- (6p-10p)

Day(s) required □ Sun

□ Mon □ Tues □ Wed □ Thurs □ Fri □ Sat

Time(s) required

M___ ___ ___

A E

M___ ___ ___

A E

M___ ___ ___

A E

M___ ___ ___

AE

M___ ___ ___

A E

M___ ___ ___

A E

M___ ___ ___

AE

Were any social, medical, rehabilitative and/or home health needs identified during the assessment? Yes ___ No ___ If “Yes”, describe ongoing social, medical, rehabilitative and/or home health needs: 1. Evidence of medical instability

2. Need for PCA services. 3. Need for home health skilled services (RN, physical therapy, and/or occupational therapy). 4. Need for other supportive services (social worker, mental health, legal, etc.) Comments:

RN Evaluator Attestation

I have completed an independent assessment of the enrollee’s needs. The information documented is an accurate interpretation of what I observed and/or was reported by the enrollee or responsible caregiver. Name: ______________________________________________________________________ (Print) (Signature and Title) Date Assessment Completed: ____________________________ Home Health Agency: ___________________________________________________ Address: ______________________________________________________________ Phone #/Fax #:_________________________________________________________ Form adapted from the Minnesota Department of Human Services, Personal Care Assistance (PCA) Assessment and Service Plan/Instructions and Guidelines (May 2009)

Health Services for Children with Special Needs, Inc.

MENTAL HEALTH SCREENING TOOL (CHILD 5 YEARS TO ADULT)

YES NO UNKNOWN RISK ASSESSMENT1. This child has a history of the behaviors or experiences listed on the

front page, “Identified Risk” section that occurred more than 90 daysago. List:

2. Does the child have problems with social adjustment? Regularlyinvolved in physical fights with other children or adults; verballythreatened people; damages possessions of self or others; runs away;truant; steals; regularly lies; mute; confined due to serious lawviolations; does not seem to feel guilt after misbehavior, etc.

3. Does this child have problems maintaining healthy relationships?Unable to form positive relationships with peers; provokes andvictimizes other children; gang involvement; does not seem to feel guiltafter misbehavior, etc.

4. Does this child have problems with personal care? Eats or drinkssubstances that are not food; regularly enuretic during waking hours(subject to age of child); extremely poor personal hygiene.

5. Does this child have significant functional impairment? No knownhistory of developmental disorder, and behavior interferes with abilityto learn at school; significantly delayed in language; “not socialized”and incapable of managing basic age appropriate skills; is selectivelymute, etc.

6. Does this child have significant problems managing his/her feelings?Severe temper tantrums; screams uncontrollably; cries inconsolably;significant and regular nightmares; withdrawn and uninvolved withothers; whines or pouts excessively; preoccupied compulsively withminor annoyances; regularly expresses feeling worthless or inferior;frequently appears sad or depressed; constantly restless or overactive,etc.

7. Does this child have a history of psychiatric hospitalization, psychiatriccare and/or prescribed psychotropic medication? Child has a history ofpsychiatric care, either inpatient or outpatient, or is taking prescribedpsychotropic medication.

8. Is this child known to abuse alcohol, cigarettes, and/or drugs? Childregularly uses alcohol, drugs or tobacco.

If any of the above boxes are checked “yes,” the child requires referral to Mental Health for an assessment to determine if services are required. Please forward a copy of this form to the member’s HSCSN Care Manager for authorization to a Mental Health Provider.

Comments/Additional Information: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MH follow-up required

Maintain in Medical Record

/ /

- -

/ /

/ /

ALL questions must be completed for authorization of services Revision: 07-13:

Obstetrical Authorization & Initial Assessment Health Plan: ---AmeriHealth---- ---HSCSN--- ---MedStar---- ---TRUSTED----- Fax Number: (888) 603-5526 (202) 721-7193 (202) 243-5496 (202) 821-1098 Tel. Number: (877) 759-6883 (866) 937-4549 (855) 210-6203 (202) 821-1096

‘

SUBMISSION DATE:

* Should this patient receive MCO Case-

management? Yes /

/

No

*Patient Referrals needed? (see below) Yes No

Provider Name (Last name, first initial)

NPI or Provider Number

Phone #

FAX#

Member name (first, middle initial, last)

Date of birth Member ID# or MA Recipient#

Home phone # Alternate phone #

English not primary language; language spoken

st Date of 1 Prenatal Visit Gestational age

wks

Gravida Para TAB Live births

-

-

EDC Hospital/Birthing Center for Delivery

HUH Providence UMC WHC GWUH Other

PAST Pregnancy

Complications

Yes

No

Gestational Diabetes

Incompetent cervix

IUGR

Preeclampsia/Eclampsia

Premature ROM

Preterm delivery <32 wks

Preterm delivery 32-36

Preterm labor <32 wks

17-P Candidate?

C-Section

Fetal lossst

(1 )nd

(2 ) rd

(3 )

Infant or child death

CURRENT Risk Factors Yes No

Bleeding: st

1nd rd

/3/ 2 (if

yes’ then circle trimester)

Abnormal placenta

Gestational diabetes

Missed Prenatal Care

Oral problems: _

Dental visit past 6 mos?

Weight gain or loss challenges

HIV

CURRENT Risk Factors (cont) Yes No

Disability:

Premature ROM

Preterm dilation of cervix (>1.5cm) or Preterm Labor (<32 weeks)

Previous delivery within 1 year

Preeclampsia/Eclampsia

Eating disorder

Hepatitis

Teen pregnancy

Head of Household

Thyroid disease

Anemia Hb <10

Asthma

Obese BMI>40, BMI>30, Overweight BMI>25, Underweight BMI<19

Chronic hypertension

Clotting disorder

Diabetes

Seizure disorder

Cardiac

Renal disease

STI

Sickle cell disease

Medications:

Referrals Needed:

Other Risks/Complications:

□

□

Revision: 07-13: DQHO

OTHER HEALTH NEEDS (please answer all questions below)

Member/ Patient Name: Date of Birth /_ _/_

Housing, Nutrition and Transportation (Circle One)

How often have you moved in the last 3 months? Are you homeless or worry that you could become homeless soon? Do you have problems getting to doctor visits or other appointments? Do you worry about getting food when you need it or getting good quality food?

Twice or more Yes Yes Yes

Once No No No

None

Home and Partner (Circle One)

How many children are now in your home or under your care? How involved is the father of your baby with your pregnancy?

3+ Not at all

2 1 Somewhat

None Very

Is your husband or partner employed? Are you employed? Do you feel that you have enough help from your family or friends to care for your new baby?

No No No

Part-time Part-time Maybe

Yes Yes Yes

If you could change the timing of this baby, would you want to? Later Earlier No Change

Experience with Child and Family Services (CFSA) or other government agencies (Circle One)

Are you currently in foster care? Yes No Has CFSA been involved with any of your children? Yes No Do you have a case manager, therapist, or counselor that you work with? Yes No Have you seen a probation officer in the last 12 months? Yes No

Reason for Late Entry into Prenatal Care (Check all that apply)

If the date of the first visit for this pregnancy was later than the first trimester (after the first 12 weeks of pregnancy) was the reason for the delay: Insurance enrollment delay Unaware of the importance of prenatal care

Childcare issues

Unable to find a health provider Financial problems

Other (specify)

Environmental Exposures (Circle One)

Have any of your children tested positive for lead poisoning? Do you have birds or cats in your home? Does anyone in your household smoke?

Yes Yes

Yes

No No

No

Domestic Violence (ACOG 3-Question Screen) (Circle One)

1. Within the past year or since you have been pregnant have you been hit, slapped, kicked, or otherwise physically hurt by someone?

Yes

No

2. Are you in a relationship with someone who threatens or physically hurts you? Yes No 3. Has anyone forced you to have sexual activities that made you feel uncomfortable? Yes No

4 Ps Plus©

Yes No

Did either of your parents have a problem with drugs or

alcohol

Does your partner have any problem with drugs or alcohol

Have you ever felt manipulated by your partner

Have you ever felt out of control or helpless

Over the past 2 weeks,

have you felt down, depressed, or hopeless

have you felt little interest or pleasure in doing things

Yes No *If an *Any is checked,

continue with the 4 Ps

Follow-Up Questions

below.

□ □

□ □

□ □

□ □

□ □

□ □

Have you ever drunk beer/wine/liquor

□ □

Any* None

In the month before you knew you were

pregnant:

how many cigarettes did you smoke □

□

□

□ how much beer/wine/liquor did you drink □

how much marijuana did you use □

4 Ps Plus Follow-up Questions (if an *Any above was checked)

In the month before you knew you were pregnant: Refer for Assessment Prevention Education No Referral Needed

every day 3-6 days/wk 1-2 days/wk < 1 day/wk (did not drink/use drugs)

About how many days a week did you usually

drink beer / wine/ liquor? □

□

□

□

□

□

□

□

□ □

□

□

□

□

□

□

□

use any drug such as marijuana, cocaine, or heroin? □ And now, about how many days a week do you usually

drink beer / wine/ liquor?

use any drug such as marijuana, cocaine, or heroin?

150

1101 Vermont Avenue, NW, Suite 1200 Washington, DC 20005

(202) 466-8483 UNUSUAL INCIDENT (UI) REPORT

Patients Initials: ________________________________________________________________________________ Patient Medicaid #: _____________________________________________________________________________ Part I - Reported By: Person first reporting incident: ____________________________________________________________________ Title/Position: __________________________________________ Phone #: ____________________________ Date/Time Reported: Month Day Yr. Time _______________________ Person Reporting Incident to HSCSN: ______________________________________________________________ Title/Position: ___________________________________________ Phone #: ________________________ Date/Time Reported: Month Day Yr. Time ______________________ Administration or Office: ________________________________________________________________________ _____________________________________________________________________________________________ Part II - Type of Incident: Type of Incident: _______________________________________________________________________________ Date/Time of Incident: Month ______________________ Day Yr. Time Location/Place of Incident: _______________________________________________________________________ Person (s) Involved: ____________________________________________________________________________ Part III - Details of Incident: (What, How, Why): _____________________________________________________________________________ Part IV - Action (s) Taken & By Whom

151

Part V - (for HSCSN Quality/Accreditation Department Use) Care Manager Receiving Report: __________________________________________________________________ Reviewed By: _________________________________________________________________________________ Date/Time Reported: Month Day Yr. Time ________________ Reported to: (Check or Specify Name): Med. Director Director ______ Team Leader _________________ Date/Time Reported: Month Day Yr. Time ________________ * If necessary, attach separate sheet for additional pertinent documentation. HSCSN - 01/29/07

152

153

154

Appendix B – Acronyms ABHW: Association for Behavioral Health and Wellness ACIP: Advisory Committee on Immunization Practices ACOG: American College of Obstetricians and Gynecologists ADA: Americans with Disabilities Act ALOS: Average Length of Stay APRA: Addiction Prevention and Recovery Administration CAHPS: Consumer Assessment of Healthcare Providers and Systems CARF: Commission on Accreditation of Rehabilitation Facilities CASSIP: Child and Adolescent Supplemental Security Income Program CBI: Community Based Intervention CFR: Code of Federal Regulations CFSA: Child and Family Services Agency CHIP: State Children’s Health Insurance Program CLIA: Clinical Laboratory Improvement Amendment CMO: Chief Medical Officer CMS: Centers for Medicare and Medicaid Services CQI: Continuous Quality Improvement CQIC: Continuous Quality Improvement Committee CQIP: Continuous Quality Improvement Plan CRNP: Certified Registered Nurse Practitioner DAW: Dispense as Written DCHFP: District of Columbia Healthy Families Program DCPS: District of Columbia Public Schools DISB: Department of Insurance, Securities and Banking DME: Durable Medical Equipment DMH: Department of Mental Health DOH: Department of Health DRG: Diagnostic Related Group DSM-IV: Diagnostic and Statistical Manual of Mental Disorders DUR: Drug Utilization Review DYRS: Department of Youth Rehabilitative Services EOB: Explanation of Benefits EPSDT: Early and Periodic Screening, Diagnosis, and Treatment EQR: External Quality Review EQRO: External Quality Review Organization ER: Emergency Room EVS: Eligibility Verification System FFS: Fee- for-Service FQHC: Federally Qualified Health Center HCFA: Health Care Finance Administration HEDIS: Health Employer Data and Information Set HIPAA: Health Insurance Portability and Accountability Act HIT: Health Information Technology

Appendix B

155

HIV/AIDS: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HPV: Human Papillomavirus ICF/MR: Intermediate Care Facilities for Mental Retardation IDEA: Individuals with Disabilities Education Act IEP: Individualized Education Plan IFSP: Individualized Family Services Plan IOM: Institute of Medicine IOP: Intensive Outpatient Program LEP: Limited or No English Proficiency MCO: Managed Care Organization MD: Medical Doctor MH: Mental Health MHRS: Mental Health Rehabilitation Services MIS: Management Information System MMCP: Medicaid Managed Care Program MST: Multi-systemic Therapy NAIC: National Association of Insurance Commissioners NCQA: National Committee for Quality Assurance NDC: National Drug Code NF: Nursing Facility NICU: Neonatal Intensive Care Unit OB/GYN: Obstetrics/Gynecology OIG: Office of Inspector General, U.S. Department of Health and Human Services OTMP: Outreach and Transition Monitoring Plan PBM: Pharmacy Benefits Manager PCP: Primary Care Physician PHP: Partial Hospitalization Program PIHP: Prepaid Inpatient Health Plan PMPM: Per Member Per Month QI: Quality Improvement QISMC: Quality Improvement System for Managed Care RN: Registered Nurse SA: Substance Abuse SSI: Supplemental Security Income TANF: Temporary Assistance for Needy Families TPL: Third Party Liability TTD: Telecommunications Device for the Deaf TTY: Teletype VFC: Vaccines for Children WIC: Special Supplemental Nutrition Program for Women, Infants and Children

Caring.�Serving.�Empowering.

Health Services for Childrenwith Special Needs, Inc.

(HSCSN)

Caring.�Serving.�Empowering.

Health Services for Childrenwith Special Needs, Inc.

(HSCSN)

1101 Vermont Avenue, NW | 12th Floor | Washington, DC 20005Main Number: (202) 466-8483 | Fax: (202) 466-8514

This program is funded in part by the Government of the District of Columbia Department of

Health Care Finance.