King County Behavioral Health Organization · BHOs administer services by contracting with...

King County Behavioral Health Organization External Quality Review Report

Department of Social and Health Services

Division of Behavioral Health and Recovery

December 2017

Qualis Health prepared this report under contract with the Washington State Department of Social and

Health Services Division of Behavioral Health and Recovery (Contract No. 1534-28375).

As Washington’s Medicaid external quality review organization (EQRO), Qualis Health provides external

quality review and supports quality improvement for enrollees of Washington Apple Health managed care

programs and managed behavioral healthcare services. Our work supports the Washington State Health

Care Authority (HCA) and Department of Social and Health Services (DSHS) Division of Behavioral

Health and Recovery (DBHR).

This report has been produced in support of the DSHS DBHR, documenting the results of external review

of the state’s Behavioral Health Organizations (BHOs). Our review was conducted by Ricci Rimpau, RN,

BS, CPHQ, CHC, Operations Manager; Crystal Didier, M.Ed, Clinical Quality Specialist; Wesley Jordan,

MS, Clinical Quality Specialist; Lisa Warren, Clinical Quality Specialist; and Joe Galvan, Project

Coordinator.

Qualis Health is one of the nation’s leading population health management organizations, and a leader in

improving care delivery and patient outcomes, working with clients throughout the public and private

sectors to advance the quality, efficiency, and value of healthcare for millions of Americans every day. We

deliver solutions to ensure that our partners transform the care they provide, with a focus on process

improvement, care management, and effective use of health information technology.

For more information, visit us online at www.QualisHealth.org/WAEQRO.

PO Box 33400

Seattle, Washington 98133-0400

Toll-Free: (800) 949-7536

Office: (206) 364-9700

Table of Contents

Table of Contents .......................................................................................................................................... 3

Executive Summary ...................................................................................................................................... 5

Introduction ...................................................................................................................................... 5

KCBHO Transition Implementation Status....................................................................................... 6

Description of EQR Activities ........................................................................................................... 7

Summary of Results ......................................................................................................................... 7

Compliance with Regulatory and Contractual Standards ........................................................................... 13

Compliance Scoring ....................................................................................................................... 13

Summary of Compliance Review Results ...................................................................................... 14

Section 1: Availability of Services .................................................................................................. 19

Section 2: Coordination and Continuity of Care ............................................................................. 25

Section 3: Coverage and Authorization of Services ...................................................................... 32

Section 4: Provider Selection ......................................................................................................... 35

Section 5: Subcontractual Relationships and Delegation .............................................................. 38

Section 6: Practice Guidelines ....................................................................................................... 40

Section 7: Health Information Systems .......................................................................................... 42

Section 8: Quality Assessment and Performance Improvement Program .................................... 44

Performance Improvement Project (PIP) Validation ................................................................................... 47

PIP Scoring .................................................................................................................................... 47

PIP Validity and Reliability ............................................................................................................. 48

PIP Validation Results: Clinical PIP ............................................................................................... 49

PIP Validation Results: Non-Clinical Children’s PIP ...................................................................... 61

PIP Validation Results: Substance Use Disorder (SUD) PIP ........................................................ 72

Information Systems Capabilities Assessment (ISCA) ............................................................................... 81

ISCA Methodology ......................................................................................................................... 81

Summary of Results ....................................................................................................................... 82

ISCA Section Details ...................................................................................................................... 84

Encounter Data Validation (EDV) ............................................................................................................... 99

Validating BHO EDV Procedures ................................................................................................... 99

Qualis Health Encounter Data Validation..................................................................................... 100

Electronic Data Checks ................................................................................................................ 100

On-site Clinical Record Review ................................................................................................... 100

Sampling Methodology................................................................................................................. 101

Scoring Criteria ............................................................................................................................ 102

KCBHO EDV Procedures............................................................................................................. 102

Qualis Health Encounter Data Validation..................................................................................... 104

Electronic Data Checks ................................................................................................................ 105

Golden Thread Focus Study ..................................................................................................................... 111

Summary of Results ..................................................................................................................... 111

Appendix A: All Recommendations Requiring Corrective Action Plans (CAPs) ....................................... 115

Appendix B: Review of Previous-Year Recommendations Requiring Corrective Action Plans (CAPs) ... 120

Appendix C: Readiness Assessment Follow-up ....................................................................................... 129

Appendix D: Coordination of Care Clinical Chart Review ......................................................................... 132

Appendix E: Regulatory and Contractual Standards ................................................................................ 135

Appendix F: Acronyms .............................................................................................................................. 163

5 Executive Summary

Executive Summary

Introduction

The Washington State Department of Social and Health Services (DSHS) Division of Behavioral Health

and Recovery (DBHR) contracts with nine Behavioral Health Organizations (BHOs) throughout the state

of Washington to provide comprehensive and culturally appropriate mental health and substance use

disorder (SUD) treatment services for adults, children, and their families. BHOs administer services by

contracting with behavioral health agencies (BHAs)—community mental health agencies, SUD treatment

providers, and private nonprofit agencies—to provide mental health and SUD services and treatment. The

BHOs are accountable for ensuring that services are delivered in an integrated manner that complies with

legal, contractual, and regulatory standards for effective care.

As the State’s external quality review organization (EQRO), Qualis Health is contracted to conduct a

yearly assessment of the accessibility, timeliness, and quality of managed mental health and SUD

treatment services provided by BHOs to Medicaid enrollees.

This report presents the results of the 2017 external quality review for King County BHO (KCBHO). In

addition to managing a network of mental health and SUD treatment providers to help Medicaid enrollees

receive inpatient treatment, outpatient treatment, and recovery support services, KCBHO provides crisis

services to the entire King County population. During 2016, KCBHO served over 47,000 distinct Medicaid

consumers residing in King County. The BHO has contracts and subcontracts with over 50 behavioral

health agencies, which include mental health agencies and SUD treatment agencies.

Because of the transition of RSNs to BHOs in April 2016 and the concurrent integration of the mental

health and SUD treatment services, DBHR directed Qualis Health to perform a readiness review for the

2016 external quality review (EQR) on the integration. The readiness review included an assessment and

evaluation of each BHO’s transition plan submitted to the State, as well as each BHO’s status in

converting from an RSN to a BHO. For the 2017 review, Qualis Health is performing a follow-up to the

2016 readiness review to ascertain the current status of each BHO’s transition.

Qualis Health’s additional EQR activities for each BHO consisted of assessing the BHO’s overall

performance and identifying strengths and opportunities for improvement regarding the BHO’s

compliance with State and federal requirements for access, timeliness, and quality measures. This

included assessing compliance with standards related, but not limited to, availability of services and

quality assessment and performance improvement; validating encounter data submitted to the State;

validating the BHO’s performance improvement projects (PIPs); and performing an Information Systems

Capabilities Assessment (ISCA). Additionally, for each BHO, Qualis Health interviewed two mental health

agencies and two SUD treatment providers. The 2017 review also includes a “Golden Thread” review of

SUD treatment services to assess for clear, consistent care linkages between an individual’s needs,

diagnosis, and treatment. Finally, Qualis Health reviewed the BHO’s previous-year recommendations.

The results of this review and the readiness review follow-up appear in Appendices B and C.

This report, in fulfillment of federal requirements under 42 CFR §438.350, describes the results of this

2017 external quality review.

6 Executive Summary

KCBHO Transition Implementation Status

At the time of the 2017 EQR, KCBHO was one year into its transition from an RSN to a BHO and

its integration of mental health and SUD treatment services. Although the transition has been

successful overall, it has also presented a number of challenges.

One of these challenges includes the BHO’s difficulty in establishing timely transmission of

encounter data by the SUD treatment agencies. KCBHO created a web portal to assist the BHAs

in submitting information in a timely manner, but at the time of the review, several providers were

still failing to submit accurate and timely data. Several SUD treatment providers, additionally,

were not performing edit checks on the data prior to submission to the BHO. To help alleviate

these problems, KCBHO hired additional staff to support the SUD treatment providers with direct

technical assistance.

Additionally, the increase in enrollees resulting from the Affordable Care Act has created the need

for additional workforce. Hiring qualified clinicians for both mental health and SUD treatment

services has posed many obstacles for the BHO. KCBHO has been actively working to develop

solutions for recruiting staff, including participating on a Washington State governor’s task force

dealing with these issues.

To account for the increase in requests for services, KCBHO has hired several staff into its

authorization and case management department who are dually licensed mental health providers

and chemical dependency professionals. The authorization and case management staff

developed new SUD treatment utilization review tools for both authorizing and monitoring SUD

treatment services. Requests for service authorizations are typically approved within 24 hours,

unless additional information is required. The BHO has also modified the payment structure for

SUD treatment services, replacing the fee-for-service model with a case rate, which has allowed

the BHO to submit payment to the agencies within a shorter timeframe.

KCBHO has undergone significant work in designing a co-occurring disorder treatment benefit and

practice guideline, collaborating with both its contracted providers and DBHR in the process. The BHO

has also been working on modifying its internal and external policies and procedures to include both

mental health and SUD treatment services. During the last year, the BHO has concentrated heavily on

educating all providers on the importance and significance of the grievance system.

Residential treatment for SUD treatment services is a new business for the BHO. The BHO stated that

over 50 percent of its enrollees are referred out of the county for these services, because King County

lacks adequate service capacity. At the time of the review, the BHO had contracts with 39 residential

treatment facilities across the state. To assist in locating available residential beds, the BHO uses a

residential bed tracker database system. Residential treatment facilities use the database to indicate

when the facility has an available bed. The tool has proven helpful in identifying available beds throughout

the state, and several other BHOs are now using the bed tracker as well.

KCBHO works together with the BHAs in helping to improve the care and services provided to its

enrollees. The BHO has made substantial progress in its transition during the prior year, and the

interviews with the contracted providers indicated there is a collaborative relationship between the BHAs

and KCBHO.

7 Executive Summary

Description of EQR Activities

EQR Federal regulations under 42 CFR §438.358 specify the mandatory and optional activities that the

EQR must address in a manner consistent with protocols of the Centers for Medicare & Medicaid

Services (CMS). This report is based on information collected from the BHO in connection with the CMS

EQR protocols and includes results from the following activities:

compliance monitoring through document review, on-site interviews at the BHO, on-site

reviews of SUD treatment provider agencies, and telephone interviews with mental health and

SUD treatment provider agencies. The purpose of the 2017 compliance review is to determine

the status of the BHO’s integration of SUD treatment and mental health agencies and the BHO’s

capability in meeting regulatory and contractual standards governing managed care.

encounter data validation (EDV) conducted through data analysis and clinical record review

validation of three performance improvement projects (PIPs) to determine whether the BHO

met standards for conducting these required studies

an Information Systems Capabilities Assessment using information collected in the ISCA

data collection tool, responses to interview questions, and results of the claims/encounter

analysis walkthroughs and security walkthroughs

follow-up on previous-year recommendations

Together, these activities answer the following questions:

1. What is the status of the integration of mental health and SUD treatment services within managed

care under the auspices of the BHO?

2. What is the status of the BHO in meeting the CMS regulatory requirements?

3. What is the status of the BHO in meeting the requirements of its contract with the State and the

Washington Administrative Code (WAC)?

4. What processes and procedures does the BHO have in place to monitor and oversee contracted

providers in their performance of any delegated activities to ensure regulatory and contractual

compliance?

5. What progress has the BHO made in conducting the three required PIPs?

6. Is the encounter data the BHAs submitted to the State accurate, complete, and valid?

7. Does the BHO’s information technology infrastructure support the production and reporting of

valid and reliable performance measures?

Summary of Results

Scoring Icon Key

● Fully Met (pass) ● Partially Met (pass) ● Not Met (fail) ● N/A (not applicable)

Compliance Review Results

This review assesses the BHO’s overall performance, identifies strengths, notes opportunities for

improvement, and recommends corrective action plans (CAPs) in areas where the BHO did not clearly or

comprehensively meet federal and/or State requirements. In addition, in cases in which the BHO has not

addressed a previous-year recommendation, Qualis Health may have issued a recommendation requiring

8 Executive Summary

a corrective action plan. The following opportunities and recommendations offer guidance on how the

BHO may achieve full compliance with State contractual and federal CFR guidelines. The results are

summarized below in Table A-1. Please refer to the compliance review section of this report for complete

results.

Table A-1: Summary Results of Compliance Monitoring Review

CMS EQR Protocol Results

Section 1.

Availability of Services

● Partially Met (pass)

Section 2.

Coordination and Continuity of Care

●Partially Met (pass)

Section 3.

Coverage and Authorization of

Services

● Fully Met (pass)

Section 4.

Provider Selection


Section 5. Subcontractual

Relationships and Delegation


Section 6. Practice Guidelines ● Partially Met (pass)

Section 7. Health Information Systems ● Partially Met (pass)

Section 8. Quality Assessment and

Performance Improvement Program


Performance Improvement Project (PIP) Validation Results

As a mandatory EQR activity, Qualis Health evaluated the BHO’s performance improvement projects to

determine whether the projects have been designed, conducted, and reported in a methodologically

sound manner. The projects must be designed to achieve, through ongoing measurements and

intervention, significant improvement sustained over time that is expected to have a favorable effect on

health outcomes and enrollee satisfaction. The results for the BHO’s clinical, non-clinical, and substance

use disorder-focused PIPs are found in Table A-2. Further discussion can be found in the performance

improvement project section of this report.

Table A-2: Performance Improvement Project Validation Results

Results Validity and Reliability

Clinical PIP: Effectiveness of the Transitional Support Program ● Partially Met (pass)

High confidence in reported results

Non-Clinical Children’s PIP: Improved Coordination with Primary Care for Children and Youth

● Partially Met (pass) Not enough time has elapsed to assess meaningful change

Substance Use Disorder (SUD) PIP: SUD Residential Treatment Length of Stay ● Partially Met (pass)

Not enough time has elapsed to assess meaningful change

9 Executive Summary

Information Systems Capability Assessment (ISCA) Results

The BHO’s information systems and data processing and reporting procedures were examined to

determine the extent to which they support the production of valid and reliable State performance

measures and the capacity to manage care of BHO enrollees.

The ISCA procedures were based on the CMS protocol for this activity, as adapted for the Washington

BHOs with DBHR's approval. For each of seven ISCA review areas, the following methods were used to

rate the BHO’s performance:

information collected in the ISCA data collection tool

responses to interview questions

results of the claims/encounter analysis walkthroughs and security walkthroughs

The organization was then ranked as fully meeting, partially meeting, or not meeting standards. Although

not rated, the BHO’s meaningful use of EHR systems for informational purposes was also evaluated.

The results are summarized below in Table A-3. Please refer to the ISCA section of this report for

complete results.

Table A-3: Results of the BHO’s Information Systems Capabilities Assessment (ISCA)

ISCA Section

Description ISCA Result

Overall ISCA Score This is the overall score for the BHO's ISCA. ● Partially Met (pass)

A. Information Systems

This section assesses the BHO’s management of the information systems.


B. IT Infrastructure This section assesses the BHO’s network infrastructure.


C. Information Security

This section assesses the security of the BHO’s information systems.


D. Encounter Data Management

This section assesses the BHO’s ability to capture and report accurate encounter data.


E. Eligibility Data Management

This section assesses the BHO’s ability to capture and report accurate Medicaid eligibility data.


F. Provider Data Management

This section assesses the BHO’s ability to maintain accurate provider information.


G. Performance Measures and Reporting

This section assesses the BHO's performance measure and reporting processes.


H. Meaningful Use of Electronic Health Records (EHRs)

This section is used to assess how the BHO and its providers use EHRs. This section is not scored.

● N/A

10 Executive Summary

Encounter Data Validation (EDV) Results

EDV is a process used to validate encounter data submitted by BHOs to the State. Encounter data are

the electronic records of services provided to BHO enrollees by both institutional and practitioner

providers (regardless of how the providers were paid), when the services would traditionally be a billable

service under fee-for-service (FFS) reimbursement systems. Encounter data are used by the BHOs and

the State to assess and improve the quality of care and to monitor program integrity. Additionally, the

State uses encounter data to determine capitation rates paid to the BHOs.

Qualis Health performed independent validation of the procedures used by the BHO to perform its own

encounter data validation. The EDV requirements included in the BHO’s contract with DBHR were used

as the standard for validation. Qualis Health obtained and reviewed the BHO’s encounter data validation

report submitted to DBHR as a contract deliverable for calendar year 2016. The BHO’s encounter data

validation methodology, encounter and enrollee sample size(s), selected encounter dates, and fields

selected for validation were reviewed for conformance with DBHR contract requirements. The BHO’s

encounter and/or enrollee sampling procedures were reviewed to ensure conformance with accepted

statistical methods for random selection. Table A-3 shows the results of the review of the BHO’s

encounter data validation processes.

Table A-3: Results of External Review of the BHO’s Encounter Data Validation Procedures

EDV Standard Description Result—Mental Health Result—SUD

Sampling Procedure

Sampling was conducted using an appropriate random selection process and was of adequate size.

●Partially Met (pass) ●Partially Met (pass)

Review Tools Review and analysis tools are appropriate for the task and were used correctly.

●Fully Met (pass) ●Fully Met (pass) Methodology and Analytic Procedures

The analytical and scoring methodologies are sound, and all encounter data elements requiring review were examined.

●Not Met (fail) ●Not Met (fail)

Qualis Health conducted its own validation to assess the BHO’s capacity to produce accurate and

complete encounter data. The encounter data submitted by the BHO to the State was analyzed to

determine the general magnitude of missing encounter data, types of potentially missing encounter data,

overall data quality issues, and any issues with the processes the BHO has in compiling encounter data

and submitting the data files to the State. Clinical record review of encounter data was performed to

validate data sent to the State and confirm the findings of the analysis of the State-level data.

Table A-4 summarizes results of Qualis Health’s EDV. Please refer to the EDV section of this report for

complete results.

Table A-4: Results of Qualis Health Encounter Data Validation


Electronic

Data Checks

Full review of encounter data

submitted to the State indicates

no (or minimal) logic problems

or out-of-range values.

●Fully Met (pass) ●Fully Met (pass)


On-site

Clinical

Record

Review

State encounter data are

substantiated in audit of patient

charts at individual provider

locations. Audited fields include

demographics (name, date of

birth, ethnicity, and language)

and encounters (procedure

codes, provider type, duration

of service, service date, and

service location). A passing

score is that 95 percent of the

encounter data fields in the

clinical records match.


Golden Thread Review of SUD Treatment Services

For the 2017 EQR focus study, Qualis Health examined the degree to which SUD treatment providers’

clinical records demonstrated adherence to the “golden thread,” a series of clear, consistent care linkages

between an individual’s needs, diagnosis, and treatment. In evaluating provider records, reviewers asked

the following questions:

1. Does the individual’s assessment contain sufficient documentation to support the diagnosis, and

does it include all of the individual’s needs?

2. Are the documented needs reflected in specific goals in the treatment plan/individual service plan

(ISP)? Does the ISP address the individual’s diagnosis and all of the identified needs in the

assessment?

3. Do the progress notes address the individual’s treatment plan goals and the needs identified in

the assessment?

To answer these questions, Qualis Health reviewed adult patient charts randomly selected from the

BHO’s EDV sample. Reviewers specifically evaluated documentation in three areas: assessments and re-

assessments, individual service planning, and progress notes. Results for these review areas are

discussed in the Golden Thread section of this report.


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13 Compliance

Compliance with Regulatory and Contractual Standards

The 2017 compliance review addresses the BHO’s compliance with federal Medicaid managed care

regulations and applicable elements of the contract between the BHO and the State. The relevant CFR

sections and results of the 2017 compliance review are included in Table B-1, below.

The CMS protocols and scoring criteria used for conducting the compliance review are included in

Appendix E. The protocols can also be found here: http://www.medicaid.gov/Medicaid-CHIP-Program-

Information/By-Topics/Quality-of-Care/Quality-of-Care-External-Quality-Review.html.

Each section of the compliance review contains elements corresponding to relevant sections of the CFR

(primarily 42 CFR Part 438), DBHR’s contract with the BHO, the Washington Administrative Code (WAC),

and other State regulations where applicable. Qualis Health evaluated King County BHO’s performance

on each element of the protocol by

performing desk audits on documentation submitted by the BHO

conducting telephone interviews with two of the BHO's contracted mental health agencies and

two of its substance use disorder (SUD) treatment providers

conducting on-site interviews with BHO staff on standards related to quality assessment and

performance improvement (QAPI) and performance improvement projects (PIPs)

performing encounter data validation (EDV)

following up on the prior year’s corrective action plans (CAPs)

following up on the prior year’s SUD treatment provider readiness review

following up on the status of the BHO’s transition plan

auditing credentialing files at selected mental health and SUD treatment provider agencies

reviewing for care coordination at selected mental health agencies

auditing for “golden thread” practices at SUD treatment provider agencies

This review assesses KCBHO’s overall performance, identifies strengths, notes opportunities for

improvement, and presents recommendations for corrective action plans (CAPs) in areas where the BHO

did not clearly or comprehensively meet federal and/or State requirements at the time of the review. The

accompanying recommendations and opportunities for improvement offer guidance on how the BHO may

achieve full compliance with State contractual, WAC, and CFR standards.

Compliance Scoring

Qualis Health uses CMS’s three-point scoring system in evaluating compliance. The three-point scale

allows for credit when a requirement is partially met and the level of performance is determined to be

acceptable. The three-point scoring system includes the following levels:

● Fully Met means all documentation listed under a regulatory provision, or component thereof, is

present and BHO staff provided responses to reviewers that were consistent with each other’s

responses and with the documentation.

● Partially Met means all documentation listed under a regulatory provision, or component

thereof, is present, but BHO staff were unable to consistently articulate evidence of compliance,

or BHO staff could describe and verify the existence of compliant practices during the

interview(s), but required documentation is incomplete or inconsistent with practice.

14 Compliance

● Not Met means no documentation is present and BHO staff had little to no knowledge of

processes or issues that comply with regulatory provisions, or no documentation is present and

BHO staff had little to no knowledge of processes or issues that comply with key components of

a multi-component provision, regardless of compliance determinations for remaining, non-key

components of the provision.

Scoring Icon Key

● Fully Met (pass) ●Partially Met (pass) ● Not Met (fail) ● N/A (not applicable)

Summary of Compliance Review Results

Table B-1: Summary Results of Compliance Monitoring Review, by Section

CMS EQR Protocol Results

Section 1.



Section 2.


●Partially Met (pass)

Section 3.

Coverage and Authorization of

Services


Section 4.

Provider Selection


Section 5. Subcontractual

Relationships and Delegation


Section 6. Practice Guidelines ● Partially Met (pass)

Section 7. Health Information Systems ● Partially Met (pass)

Section 8. Quality Assessment and

Performance Improvement Program


Summary of Opportunities for Improvement and Recommendations

Requiring Corrective Action Plans (CAPs), by Section

Section 1: Availability of Services

Opportunity for Improvement

The BHO’s last geographical mapping was performed in 2015, and the BHO stated it is committed to

completing another geo mapping by the end of 2017.

15 Compliance

With the addition of SUD treatment services, KCBHO should follow through with completing a geo

mapping by the end of 2017 to assess its network adequacy.

Recommendations Requiring CAP

Enrollee participation varies greatly among the agencies, from 9,000 enrollees for one agency to 30

enrollees for another agency. Regardless of the participation rate, workforce development remains a

major concern for the BHO.

KCBHO needs to continue to work with the BHAs in developing successful talent management

and recruitment strategies, as demand for services has increased as a result of the Affordable

Care Act and the opioid epidemic.

The BHO indicated that during its most recent administrative audit of the BHAs, the SUD treatment

agencies were not aware of how to arrange for second opinions and had not implemented policies on

second opinions. The BHO stated it provided consultation with its SUD treatment BHAs on how to

arrange for second opinions and encouraged the BHAs to adopt the BHO’s policy on second opinions.

KCBHO needs to follow up with the SUD treatment BHAs to ensure they have adopted and

implemented policies on second opinions.

KCBHO noted it does not have a system for tracking requests for out-of-network services.

KCBHO needs to implement a procedure to track requests for out-of-network services and use

this information for network planning.

KCBHO indicated it follows its credentialing policies and procedures to ensure all out-of-network

providers are appropriately credentialed. The BHO requires all out-of-network providers to complete and

sign a single-case service agreement, which requires the provider to submit license(s)/credentials and

attest to a background check, and provides assurance that the provider is not on the excluded provider

list. However, during the on-site interview, KCBHO indicated it needed to update its credentialing policies

and procedures to ensure all providers are appropriately credentialed.

KCBHO needs to update its credentialing policies and procedures to ensure all providers are

appropriately credentialed, including out-of-network providers and those with a single-case

agreement.

Section 2: Coordination and Continuity of Care


KCBHO’s 2017 on-site clinical record review tool included monitoring to ensure that documentation of

coordination of activities is evident in the enrollee’s clinical record and that communication occurs within

the scope of the consent and release(s) given by the enrollee.

KCBHO should continue its efforts, through its 2017 clinical site review monitoring, to ensure that

documentation of coordination of activities is evident in the enrollee’s clinical record and that

communication occurs within the scope of the consent and release(s) given by the enrollee.


Although KCBHO has a policy and procedure for coordinating enrollee care, the policy lacks a definition

or standard of what constitutes care coordination and how it is measured.

In its policy on enrollee care coordination, KCBHO needs to include a definition or standard of

what constitutes care coordination and how it is measured. The definition should include:

o the standard for coordinating care between settings of care

16 Compliance

o appropriate discharge planning for short-term and long-term hospital or institutional stays

o services the enrollee receives from any other BHO

o services the enrollee receives in fee-for-service (FFS) Medicaid

o services the enrollee receives from community and social support providers

KCBHO requires the BHAs to initiate a referral to a primary healthcare provider appropriate for the

enrollee’s needs when the enrollee does not have a primary healthcare provider. KCBHO stated that

through its clinical record review and monitoring of the intake process it ensures each enrollee has

access to a primary healthcare provider. The BHO has also included monitoring in its 2017 on-site clinical

record review tool to ensure that documentation of coordination of activities is evident in the enrollee’s

clinical record. However, during the BHA on-site record review conducted by the EQRO, the majority of

charts lacked evidence of care coordination with the primary healthcare provider. In addition, the 2016

summary report results from KCBHO’s administrative review indicated that the majority of agencies had

difficulty articulating coordination of care in their policies and procedures.

KCBHO needs to continue its monitoring efforts to ensure its BHAs have clearly defined care

coordination in their policies and procedures. The BHO needs to continue training, educating, and

monitoring its BHAs to ensure enrollees are referred to a primary healthcare provider when

appropriate and that care coordination is documented in the clinical record.

KCBHO’s clinical record and administrative reviews include criteria for reviewing treatment plans to

ensure the treatment plans are developed with the enrollee’s participation, and in consultation with any

specialists caring for the enrollee. However, the results of the on-site EQR of the care coordination

records indicated that some BHAs are not using or completing treatment plans and that many treatment

plans that were in place did not include enrollee voice and participation.

KCBHO needs to ensure that all BHAs have treatment plans in place and that the treatment plans

include documentation that the plans were developed with the enrollee’s participation and in

consultation with any specialists caring for the enrollee.

KCBHO does not have a policy and procedure on direct access to specialists for enrollees with special

healthcare needs.

The BHO needs to develop a policy and procedure regarding direct access to specialists for

enrollees with special healthcare needs.

KCBHO does not monitor the availability of direct access to specialists.

KCBHO needs to add criteria to its monitoring tool to assess availability of direct access to

specialists.

Section 3: Coverage and Authorization of Services

N/A

Section 4: Provider Selection


During the on-site interview, the BHO indicated it is not monitoring its BHAs to ensure they have a policy

and procedure on credentialing and re-credentialing.

KCBHO needs to add criteria to its monitoring tool in order to review each BHA’s credentialing

and re-credentialing policy and procedure.

17 Compliance

At the time of the 2017 EQR, the BHO indicated it had created an internal process to ensure monthly

exclusion checks were performed on all staff, including its BHAs. However, it was determined during the

on-site visit that the BHO is not performing monthly Office of the Inspector General (OIG) List of Excluded

Individuals and Entities (LEIE) checks on its entire staff at the BHO, including the county executives, BHO

leadership, interns, volunteers, and staff who make authorization decisions.

KCBHO needs to ensure the BHO as well as the BHAs are performing exclusion checks on a

monthly basis and at the time of hire on all staff, including county executives, BHO leadership,

board members, custodial staff, and volunteers.

Section 5: Subcontractual Relationships and Delegation


KCBHO’s BHA contracts do not contain language holding the BHAs’ subcontractors accountable for

delegated services.

KCBHO needs to add language to its BHA contracts that clarifies that BHA subcontractors are

accountable for any delegated services.

KCBHO does not include delegation monitoring in its annual QA evaluation.

KCBHO needs to add delegation monitoring to its annual QA evaluation.

Section 6: Practice Guidelines


Although KCBHO posts its practice guidelines on its website, they are not easy to locate. The titles are

not self-explanatory, and the guidelines are filed in the Quality Management and Extraordinary

Occurrences section of the website as appendices, which could make it very difficult for enrollees and

providers to access them.

KCBHO should consider including “practice guidelines” in the title of the practice guidelines

located on the BHO’s website in order to make them easily identifiable for both enrollees and

providers.

Recommendation Requiring CAP

KCBHO’s policy states that practice guidelines are disseminated to all affected providers and, upon

request, to enrollees, but it does not specify the mechanism or frequency of distribution.

KCBHO needs to include in its policy the mechanism and frequency with which it distributes the

practice guidelines to providers and enrollees.

Section 7: Health Information Systems


The BHO does not have an external policy and procedure to ensure its BHAs are checking their data for

quality and integrity before submitting them to the BHO.

The BHO needs to create and implement a policy and procedure to ensure its BHAs are checking

their data for quality and integrity before submitting them to the BHO. The policy should include:

o the requirement for providers to submit written attestations of data accuracy

o a form letter for providers to complete attesting to data accuracy

o a system for the form letters to be transmitted electronically to the BHO

18 Compliance

o monitoring by BHO contract monitors to ensure timely submission of the attestation

letters

KCBHO reported that the SUD treatment BHAs were experiencing challenges submitting data in the file

formats required by the Service Encounter Reporting Instructions (SERI) as this was a new requirement

for the providers. The SUD treatment BHAs were encouraged to use a web portal the BHO designed for

data submission until the challenges were resolved. However, the EQRO was unable to perform EDV at

the time of the review because the SUD treatment BHAs had not submitted all of the required data.

KCBHO needs to continue to train and assist its SUD treatment BHAs to ensure the BHAs can

submit timely, accurate, and complete data.

Section 8: Quality Assessment and Performance Improvement Program


KCBHO does not comply with the State Quality Strategy as the State does not have a current quality

strategy.

KCBHO will need to comply with the State Quality Strategy once the State has developed and

implemented its plan.


In the past year, KCBHO has not been able to report all of its SUD treatment performance data to the

State.

KCBHO needs to continue to monitor and support its SUD treatment BHAs in order to ensure it

receives all performance data.

19 Compliance


Table B-2: Summary of Compliance Review for Availability of Services

Protocol Section CFR Result


1. Delivery Network/Network Adequacy

Standards

438.206 (b)(1), 438.68 ● Partially Met (pass)

2. Second Opinion 438.206 (b)(3) ● Partially Met (pass)

3. Out-of-network Services 438.206 (b)(4) ● Partially Met (pass)

4. Payment of Out-of-network Services 438.206 (b)(5)

● Fully Met (pass) 5. Provider Credentials 438.206 (b)(6), 438.214


6. Timely Access 438.206 (c)(1)


7. Access and Cultural Considerations 438.206 (c)(2–3) ● Fully Met (pass) Overall Result for Section 1. ● Partially Met (pass)

Delivery Network/Network Adequacy Standards: 438.206 (b)(1), 438.68

Scoring Criteria

The BHO maintains and monitors an appropriate network of BHAs that is supported by

written agreements.

The BHO’s BHA network is sufficient to provide adequate access to all services covered

under the contract.

The BHO annually conducts geo mapping that includes the cultural, ethnic, racial, and

linguistic needs of its members; distance; travel time; the means of transportation

ordinarily used by Medicaid enrollees; and whether the location provides physical access

for Medicaid enrollees with disabilities.

In establishing and maintaining the network, the BHO considers:

o the anticipated Medicaid enrollment

o the expected utilization of services, taking into consideration the characteristics and

healthcare needs of specific Medicaid populations represented in the BHO

o the numbers and types (training, experience, and specialization) of BHAs required to

furnish the contracted Medicaid services

o the number of network BHAs that are not accepting new Medicaid patients

The BHO has formal procedures in place to monitor its BHA network to ensure adequacy.

Reviewer Determination


20 Compliance

Strengths

KCBHO created its internal policy and procedure Managing Network Sufficiency as a mechanism

to monitor change in network sufficiency and to provide reports to DBHR in a timely fashion.

KCBHO regularly monitors its network sufficiency by measuring and reviewing:

o the penetration rate of enrollees in both SUD treatment and mental health services

o service utilization patterns, including provider caseloads

o enrollees’ timely access to care and services

o the geographic location of providers and Medicaid enrollees, considering distance,

travel time, and the means of transportation ordinarily used by enrollees

o contractor and subcontractor compliance with Americans with Disabilities Act (ADA)

requirements for physical access

o availability of specialists

o use of clinical services

o provision of outreach services

KCBHO stated it has a mix of culturally diverse agencies that primarily provide services to

enrollees of Hispanic, Asian, and African-American descent.

Several of the BHO’s contracted BHAs have systems in place, including mobile medical vans

and visiting medical staff, to provide care to enrollees who have both mental health and medical

needs.

KCBHO described how the BHO maintains and monitors an appropriate network of BHAs that is

supported by written agreements. At the time of the EQR, the BHO had 40 direct contract

providers and 22 subcontracted providers and continues to:

o monitor its BHAs to measure and anticipate growth

o determine through dialogue with new agencies which populations they are bringing to the

network

o interview potential providers to determine if they can help meet the needs of the county’s

various populations

The BHO has been proactive by meeting with enrollees and asking for their feedback on needed

services. The BHO has expanded this program to include enrollees with multiple uses of the

crisis system to help identify service needs and decrease the use of the crisis system.


The BHO’s last geographical mapping was performed in 2015, and the BHO stated it is committed to

completing another geo mapping by the end of 2017.

With the addition of SUD treatment services, KCBHO should follow through with completing a geo

mapping by the end of 2017 to assess its network adequacy.





KCBHO needs to continue to work with the BHAs in developing successful talent management



21 Compliance

Second Opinion: 438.206 (b)(3)

Scoring Criteria

The BHO maintains policies and procedures related to second opinions that meet the

contract and WAC standards.

BHO staff are knowledgeable about State and federal requirements, as well as internal

policies and procedures.

The BHO provides literature or other materials available to enrollees to provide

information about the enrollee’s right to a second opinion.

The BHO provides for a second opinion from a qualified healthcare professional within

the network, or arranges for the enrollee to obtain one outside the network, at no cost to

the enrollee.

The BHO has an effective process in place to monitor compliance with standards.



Strengths

KCBHO’s policy and procedure 4.17 Client Second Opinion is well written and includes the

requirement that providers develop policies and procedures for providing requested second

opinions. The policy also states that providers may request that second opinions be arranged with

another provider agency within the KCBHO network. Such a request must be made in writing to

KCBHO’s Client Assistance Services and be accompanied by an explanation describing why the

opinion cannot be provided at the enrollee’s current agency. Second opinions are provided at no

cost to the enrollee.

KCBHO staff are very knowledgeable about the BHO’s second opinion policy. The contract

monitoring staff audit the agencies’ policies on second opinions during the yearly administration

review.

KCBHO requires that the second opinion occur within 30 days of the enrollee’s request,

unless the enrollee requests a delay.






KCBHO needs to follow up with the SUD treatment BHAs to ensure they have adopted and


Out-of-network Services: 438.206 (b)(4)

Scoring Criteria

The BHO provides documentation of adequate and timely covered services for out-of-

network enrollees when the network is unable to provide necessary services covered

under the contract.

The BHO provides up-to-date existing agreements and/or contracts with out-of-network

providers.

22 Compliance

The BHO has a process to track out-of-network encounters and reviews this information for

network capacity planning.



Strength

KCBHO stated its network of providers is able to provide all services to enrollees except for

eating disorder treatment services. If the BHO receives a request for a referral for eating disorder

treatment, the BHO works very closely with the provider agency to establish the treatment plan

and arrange the services.



KCBHO needs to implement a procedure to track requests for out-of-network services and use


Payment of Out-of-network Services: 438.206 (b)(5)

Scoring Criteria

The BHO has a documented process and policy that require out-of-network providers to

coordinate with the BHO with respect to payment.

The BHO has a documented process for how out-of-network providers are paid.

The BHO ensures and has a documented policy and process that cost to the enrollee is

not greater than it would be if the out-of- network services were furnished within the

network.

The BHO has a process for the action taken if an enrollee receives a bill for out-of-network

services.



Strength

KCBHO has an appropriate policy covering how services not currently provided within the

network are paid for and documented, and clarifying that the cost of these services to the enrollee

is no greater than it would be for in-network services.

Provider Credentials: 438.206 (b)(6), 438.214

Scoring Criteria

The BHO has a documented process and policy to ensure that its network providers are

appropriately credentialed.






23 Compliance





KCBHO needs to update its credentialing policies and procedures to ensure all providers are


agreement.

Timely Access: 438.206 (c)(1)

Scoring Criteria

The BHO has and implements a policy for timely access.

The BHO requires its providers to meet State Medicaid standards for timely access to

care and services.

The BHO ensures that the network BHAs offer hours of operation that are no less than the

hours of operation offered to commercial enrollees or comparable to Medicaid fee-for-

service, if the BHA serves only Medicaid enrollees.

The BHO has established mechanisms to ensure services included in the contract are

available 24 hours a day, 7 days a week, when medically necessary.

The BHO takes corrective action and has documentation of such corrective action if BHAs fail to

comply with access standards.



Strengths

KCBHO is monitoring and tracking its BHAs in several areas to assess timely access to care.

During the last four years, the BHO has witnessed a steady incline in the percentage of enrollees

who are receiving services within 14 days of a request for service. In 2016, BHAs were meeting

the stated goals for 84 percent of clients, compared to 73 percent in 2015.

In July 2015, the BHO issued a CAP to one of its BHAs for non-compliance with access

standards. KCBHO provided evidence that the BHO monitored the BHA’s implementation of the

corrective action plan.

Access and Cultural Considerations: 438.206 (c)(2–3)

Scoring Criteria

The BHO has a documented policy and procedure related to the delivery of services in a

culturally competent manner to all enrollees, including those with limited English

proficiency and diverse cultural and ethnic backgrounds.

The BHO monitors and has documented tracking of the delivery of services to those with

limited English proficiency and diverse cultural and ethnic backgrounds.

The BHO has documentation of any cultural competency training(s).

The BHO has a documented policy and procedure related to accessibility considerations

to ensure that BHAs provide physical access, reasonable accommodations, and

accessible equipment for Medicaid enrollees with physical or mental disabilities.

The BHO monitors its BHAs to ensure they provide adequate physical access, reasonable

accommodations, and accessible equipment for Medicaid enrollees with physical or mental

24 Compliance

disabilities.



Strengths

KCBHO’s policies pertaining to cultural competency are comprehensive and well written. They

specify that services be “age appropriate, culturally relevant and linguistically competent.”

KCBHO’s policy Purpose of the King County Behavioral Health Plan articulates that through the

choice of providers in the network, the BHO provides access to care, appropriate levels of care,

and services that are both age appropriate and culturally relevant.

KCBHO maintains several programs and contracts to provide services for enrollees from diverse

cultural and ethnic backgrounds.

The 2017 administrative contract review includes assessing how the BHAs provide services that

are:

o culturally responsive, including awareness of racial and ethnic factors impacting

treatment, and informed by the cultural context of the individual

o linguistically appropriate

o responsive to the needs of persons with disabilities

o appropriate to the chronological age and developmental needs of the individual

o trauma-informed

o attuned to promoting recovery and resiliency

25 Compliance


Table B-3: Summary of Compliance Review for Coordination and Continuity of Care



Primary Care and Coordination of

Healthcare Services

438.208 (b)(1–5) ● Not Met (fail)

Enrollee Privacy and HIPAA Compliance 438.208 (b)(6)

45 CFR 160.310,

160.316


Confidentiality of Records 42 U.S.C. 290dd–2 ● Fully Met (pass)

Confidentiality of Alcohol and Drug Abuse

Patient Records—Access and

Restrictions

2.12 (a–c), 2.16 (a),

2.19, 2.22 (a–c), 2.23 ● Fully Met (pass)

Confidentiality of Alcohol and Drug Abuse

Patient Records—Audit and Evaluation

2.53 ● Fully Met (pass)

Distribution of Enrollee Information 431.300 (a–c),

431.301, 431.302,

431.307 (a)(1)


Additional Services for Enrollees with

Special Healthcare Needs

438.208 (c)(2) ● Fully Met (pass)

Treatment/Service Plans 438.208 (c)(3) ● Not Met (fail)

Direct Access to Specialists 438.208 (c)(4)

● Not Met (fail)

Overall Result for Section 2. ●Partially Met (pass)

Primary Care and Coordination of Healthcare Services: 438.208 (b)(1–5)

Scoring Criteria

The BHO must have and implement a policy and procedure for delivering care and coordinating

healthcare services for all enrollees.

The BHO must ensure enrollees have an ongoing source of care appropriate for their needs and

access to providers responsible for coordinating enrollees’ care and services.

The BHO ensures that each enrollee has access to a primary healthcare provider appropriate to

the enrollee’s needs.

The BHO has a process in place to communicate enrollees’ healthcare needs with other service

providers to prevent duplication of activities.

The BHO has a process in place to monitor care coordination and other healthcare services

furnished to enrollees with its BHAs.


● Not Met (fail)

26 Compliance


KCBHO’s 2017 on-site clinical record review tool included monitoring to ensure that documentation of

coordination of activities is evident in the enrollee’s clinical record and that communication occurs within

the scope of the consent and release(s) given by the enrollee.

KCBHO should continue its efforts, through its 2017 clinical site review monitoring, to ensure that

documentation of coordination of activities is evident in the enrollee’s clinical record and that

communication occurs within the scope of the consent and release(s) given by the enrollee.




In its policy on enrollee care coordination, KCBHO needs to include a definition or standard of
















KCBHO needs to continue its monitoring efforts to ensure its BHAs have clearly defined care




Enrollee Privacy and HIPAA Compliance: 438.208 (b)(6), 45 CFR 160.310, 160.316

Scoring Criteria

The BHO ensures that in the process of coordinating care, each enrollee’s privacy is protected in

accordance with the privacy requirements of HIPAA (45 CFR 160).

The BHO monitors for compliance to HIPAA regulations and takes action to correct any

deficiencies.

The BHO has a policy and procedure to provide its own records and compliance reports, as well

as those of its covered entities or business associates, indicating all parties will comply with

applicable HIPAA administrative simplification provisions.

The BHO has a policy and procedure to ensure a covered entity or business associate may not

threaten, intimidate, coerce, harass, discriminate against, or take any other retaliatory action

against any individual or other person for filing a complaint with the State regarding HIPAA

compliance.

The BHO has a policy and procedure in place ensuring the BHO and its contracted entities

cooperate with HIPAA complaint investigations and compliance reviews.

27 Compliance



Strengths

KCBHO’s policies Privacy and Security of Information Systems Data and Client Records and

Confidentiality of Client Records are both comprehensive and well written. Each policy thoroughly

addresses how the BHO and BHAs shall comply with HIPAA requirements.

Additionally, KCBHO requires its BHAs to develop comprehensive information security and

privacy policies and procedures to ensure data security and the protection and confidentiality of

client records.

KCBHO has a privacy officer who is responsible for the oversight and monitoring of all client

information and protected health information (PHI).

The privacy officer reviews each routine and recurring disclosure of PHI to ensure it meets the

minimum necessary restriction, when that restriction applies.

All BHO and BHA staff are required to annually participate in confidentiality training.

KCBHO has worked closely with the BHAs to define the information that can be shared and with

whom it can be shared.

To support an individual’s recovery, KCBHO ensures that each enrollee’s privacy is protected by

obtaining releases of information at intake, and throughout treatment, to allow for cooperative

service planning, information sharing, crisis planning, and safe prescribing of medications.

Confidentiality of Records: 42 U.S.C. 290dd–2

Scoring Criteria

The BHO has a policy and procedure to deliver care to and coordinate healthcare services for all

enrollees ensuring confidentiality and appropriate disclosure only with the enrollee’s consent.


enrollees identifying the purposes and circumstances of disclosure affecting the enrollee

regardless of consent.



Strength

The BHO has several memorandums of understanding (MOUs) and data sharing agreements

with various entities and health plans and actively meets with several MCOs to share information

on enrollees with comorbidities.

Confidentiality of Alcohol and Drug Abuse Patient Records—Access and Restrictions:

2.12 (a–c), 2.16 (a), 2.19, 2.22 (a–c), 2.23

Scoring Criteria

28 Compliance


accordance with the privacy requirements detailed in 42 CFR Part 2.

The BHO has a policy and procedure to ensure that when coordinating care for enrollees, the

BHO and its business associates, covered entities, and contracted providers follow restrictions on

disclosure of enrollee information, security for written records, and disposition of records for

discontinued programs.

The BHO has a policy and procedure to ensure the confidentiality of enrollee drug and alcohol

records, including when disclosure will be granted, patient access, and restrictions on use of

information.

The BHO has a process in place to monitor its BHAs for care coordination and all other healthcare

services furnished to enrollees to make certain policies regarding confidentiality of enrollee drug

and alcohol records, as well as disclosure, enrollee access, and restrictions on use of information

are followed.

The BHO notifies enrollees of the circumstances in which disclosure is permitted without the

enrollee’s consent.



Strengths

KCBHO’s Privacy and Security Committee is responsible for developing and implementing

privacy and security policies and procedures; reviewing and modifying policies and procedures

related to electronic technology as technology changes; monitoring adherence by the BHO and

BHAs to the privacy and security policies and procedures; and reviewing and approving training

curricula for new staff at point of hire as well as curricula for ongoing training for current staff. The

committee is chaired by the privacy officer, and meetings are attended by both the compliance

and security officers.

KCBHO’s enrollees receive a Notice of Privacy Practices, which informs them of privacy rights

and how to exercise them; how the BHO accesses, uses, and discloses PHI without client

consent or authorization; and how the BHO protects client privacy.

Confidentiality of Alcohol and Drug Abuse Patient Records—Audit and Evaluation: 2.53

Scoring Criteria

The BHO has a procedure and policy in place that describe the auditing and evaluation of SUD

treatment records in accordance with §2.53.

The BHO has a process in place to ensure that if enrollee records are copied or removed from a

BHA during an audit, the confidentiality of PHI is maintained in accordance with the security

requirements discussed in 42 CFR.

The BHO has a process in place to make sure all PHI removed from the BHAs during an audit is

destroyed upon completion of the audit.



Meets Criteria

29 Compliance

Distribution of Enrollee Information: 431.300 (a–c), 431.301, 431.302, 431.307 (a)(1) Scoring Criteria


accordance with the privacy requirements in §§431.300, 431.301, and 431.302.

The BHO has a policy and procedure in place to ensure information exchanged by the BHO and

its BHAs is made available only to the extent necessary to assist in the valid administrative needs

of the program receiving the information and is adequately stored and protected against

unauthorized disclosure.

The BHO has a mechanism in place to monitor that distribution of information directly relates to

the administration of the State plan.



Strengths

KCBHO’s privacy officer and the King County Information Technology (KCIT) Security Team are

responsible for ensuring that privacy and security policies and procedures are adequate and are

implemented within KCBHO.

KCBHO’s policy and procedure on confidentiality includes:

o how the BHO ensures that information exchanged by the BHO and its BHAs is made

available to other entities only to the extent necessary to assist in the valid administrative

needs of the program receiving the information

o how the BHO ensures that in the process of coordinating care, each enrollee’s privacy is

protected in accordance with the privacy requirements specified in the CFR

o how the BHO monitors that distribution of information directly relates to the administration

of the State plan

Additional Services for Enrollees with Special Healthcare Needs: 438.208 (c)(2)

Scoring Criteria

The BHO has a policy and procedure for assessing each enrollee in order to identify any ongoing

special conditions that may require a special course of treatment or regular care monitoring.

The BHO has a method for identifying enrollees with special healthcare needs. Special healthcare

needs include any physical, developmental, mental, sensory, behavioral, cognitive, or emotional

impairment or limiting condition that requires medical management, healthcare intervention, and/or

use of specialized services or programs. The condition may be congenital or developmental, or

acquired through disease, trauma, or environmental cause and may impose limitations in

performing daily self-maintenance activities or substantial limitations in a major life activity.

The BHO has a process in place to monitor compliance with this requirement.

The BHO has in effect mechanisms to detect both underutilization and overutilization of services,

and to assess the quality and appropriateness of care furnished to enrollees with special

healthcare needs.



30 Compliance

Strengths

The BHO has a method for identifying enrollees with special healthcare needs. Per policy and

procedure, KCBHO requires its BHAs to obtain and document the following information for

individuals receiving outpatient services:

o the name of any current primary medical care provider

o any current physical health concerns

o current medications and any related concerns

o history of any substance use/abuse and treatment, including tobacco use

o any disabilities or special needs

KCBHO has a mechanism in place to monitor and manage service utilization by ensuring

providers:

o have a comprehensive utilization management process that identifies patterns of service

utilization by all clients, and strategies to ensure that the right services are provided at the

right time in the right place

o review the agency-specific outpatient service utilization reports provided by KCBHO to

identify service utilization patterns for all mental health outpatient benefits

o develop and implement protocols for the utilization management of their clients who are

frequently served by other costly systems, such as residential or inpatient psychiatric

care

KCBHO tracks enrollees who have had three or more authorized psychiatric hospitalizations or

multiple residential SUD treatment admissions in the preceding 12 months and works with

providers to provide case management for these enrollees.

Treatment/Service Plans: 438.208 (c)(3)

Scoring Criteria

The BHO ensures that treatment plans for enrollees with special healthcare needs are developed

with the enrollee’s participation and in consultation with any specialists caring for the enrollee.

The enrollee’s treatment plan incorporates the enrollee’s special healthcare needs.


● Not Met (fail)







KCBHO needs to ensure that all BHAs have treatment plans in place and that the treatment plans



Direct Access to Specialists: 438.208 (c)(4)

Scoring Criteria

The BHO has policies and procedures regarding direct access to specialists for enrollees with

special healthcare needs.

31 Compliance

The BHO monitors the availability of direct access to specialists.


● Not Met (fail)



healthcare needs.

The BHO needs to develop a policy and procedure regarding direct access to specialists for



KCBHO needs to add criteria to its monitoring tool to assess availability of direct access to

specialists.

32 Compliance


Table B-4: Summary of Compliance Review for Coverage and Authorization of Services


Coverage and Authorization of Services

Coverage 438.210 (a) ● Fully Met (pass)

Authorization of Services 438.210 (b) ● Fully Met (pass)

Notice and Timeliness of Adverse Benefit

Determination

438.210 (c), 438.404 ● Fully Met (pass)

Timeframe for Decisions, Standard and

Expedited

438.210 (d)(1–2) ● Fully Met (pass)

Compensation for Utilization Management

Activities

438.210 (e) ● Fully Met (pass)

Emergency and Post-Stabilization Services 438.114 ● Fully Met (pass)

Overall Result for Section 3. ● Fully Met (pass)

Coverage: 438.210 (a)

Scoring Criteria

The BHO monitors to ensure that services are provided in an amount, duration, and scope

sufficient to achieve the purpose for which they are provided.

The BHO does not arbitrarily deny or reduce the amount, duration, or scope of a required service

solely because of diagnosis, type of illness, or condition of the beneficiary.

The BHO applies the State’s standard for medical necessity when monitoring provided services

and making authorization decisions.



Strengths

KCBHO’s policy on outpatient level of care services includes the State’s standard for medical

necessity for both mental health and SUD treatment services.

KCBHO’s care managers are licensed mental health professionals. The reviewers for SUD

treatment services are chemical dependency professionals (CDPs).

All requests for services are sent electronically to the BHO, which uses an algorithm based on the

level of care to approve services for the amount, duration, and scope sufficient to achieve the

purpose for which they are requested.

Authorization of Services: 438.210 (b)

Scoring Criteria

33 Compliance

The BHO has documented policies and procedures for the consistent application of review criteria

pertaining to the initial and continuing authorization of services.

The BHO consults with the requesting BHA when appropriate.

The BHO has a process to ensure that any decision to deny a service authorization request or to

authorize a service in an amount, duration, or scope that is less than requested is made by a

mental health or chemical dependency professional who has appropriate clinical expertise in

treating the enrollee's condition or disease.

In the event of an inpatient stay, only a psychiatrist or clinical psychologist can issue a denial for

inpatient psychiatric services.



Strengths

When problematic patterns of service use are identified, such as multiple uses of crisis services,

KCBHO’s care managers step in to manage and implement service plans. When needed,

KCBHO’s medical director assists in managing complex and sensitive enrollee cases.

KCBHO’s policy Client Services 3B Review Inter-Rater Reliability describes the procedure for

validating inter-rater reliability.

Notice and Timeliness of Adverse Benefit Determination: 438.210 (c), 438.404

Scoring Criteria

The BHO has a documented policy and procedure to notify the requesting BHA and the enrollee in

writing of any decision by the BHO to deny an initial or continuing service authorization request, or

to authorize a service in an amount, duration, or scope that is less than requested.

The BHO ensures the notice meets the requirements of §438.404.



Meets Criteria

Timeframe for Decisions, Standard and Expedited: 438.210 (d)(1–2)

Scoring Criteria

The BHO has a documented policy and procedure for standard and expedited authorization

decisions. The BHO has a process for tracking standard and expedited authorization decisions.

The BHO has mechanisms in place to ensure compliance with standard and expedited

authorization timeframes.



Strength

Interviews with KCBHO’s BHAs indicated that the turnaround time for standard authorizations is

well within three days and that decisions are usually made within 24 hours.

34 Compliance

Compensation for Utilization Management Activities: 438.210 (e)

Scoring Criteria

The BHO has a documented policy and procedure specifying that compensation to individuals or

entities that conduct utilization management activities is not structured so as to provide incentives

for the individual or entity to deny, limit, or discontinue medically necessary services to any

enrollee.

The BHO has mechanisms in place to ensure BHAs and/or utilization management contractors do

not provide staff with incentives to deny, limit, or discontinue medically necessary services.



Strength

KCBHO’s contracts and policies and procedures confirm that provider compensation is not

structured to provide incentives for providers to deny, limit, or discontinue medically necessary

services to enrollees.

Emergency and Post-stabilization Services: 438.114

Scoring Criteria

The BHO has written policies and procedures pertaining to crisis, stabilization, and post-hospital

follow-up services.

The BHO pays for treatment of conditions defined in its policies as urgent or emergent conditions.

The BHO tracks and monitors to ensure that there is no payment denial for crisis services.

The BHO tracks and monitors use of crisis services for inappropriate or avoidable use related to

access to routine care.



Strength

KCBHO has several robust policies and procedures for crisis response, evaluation and treatment,

and stabilization services. The BHO does not require authorization for these services, and the

policies state that these services are available at no cost to the enrollee.

35 Compliance


Table B-5: Summary of Compliance Review for Provider Selection


Provider Selection

Credentialing and Re-credentialing 438.214 (a),(b),(e) ● Partially Met (pass)

Nondiscrimination of Providers 438.214 (c), 438.12 ● Fully Met (pass)

Excluded Providers 438.214 (d) ● Partially Met (pass)

Overall Result for Section 4. ● Partially Met (pass)

Credentialing and Re-credentialing: 438.214 (a),(b),(e)

Scoring Criteria

The BHO has a credentialing and re-credentialing policy and procedure for providers who have

signed contracts or participation agreements.

The BHO has a documented process for credentialing.

The BHO has a documented process for re-credentialing.

The BHO annually monitors the credentialing and re-credentialing process.

The BHO ensures the BHAs have credentialing and re-credentialing polices and processes in

place.



Strengths

KCBHO’s Credentialing and Contract Monitoring policy was adopted on March 1, 2016, and

became effective on April 1, 2016. The policy indicates that provider and subcontractor

credentialing/re-credentialing is conducted prior to contracting for the ensuing year.

BHAs seeking participation in the KCBHO network must fill out a credentialing application, which

is then reviewed by the BHO’s contracting review team. Additional review steps include an on-

site visit with the provider by the contract monitors. The on-site review includes:

o a facility walkthrough

o review of encounter data

o review of clinical files

o review of policies and procedures

o review of utilization management/quality improvement plans

During an interview with a contracted BHA, the BHA indicated that it applied for a contract with

the BHO in 2016. The BHA described the application process as extremely comprehensive; the

agency was requested to provide evidence of licensure, accreditation, relevant policies and

36 Compliance

procedures, insurance, clinician qualifications, and certification. The BHA also underwent a re-

credentialing process at contract renewal.




KCBHO needs to add criteria to its monitoring tool in order to review each BHA’s credentialing


Nondiscrimination of Providers: 438.214 (c), 438.12

Scoring Criteria

The BHO has provider selection policies and procedures, consistent with §438.12, that ensure the

BHO does not discriminate against particular providers that serve high-risk populations or

specialize in conditions that require costly treatment.

The BHO has policies and procedures in place that ensure the BHO does not discriminate in the

participation, reimbursement or indemnification of any provider who is acting within the scope of

their license or certification, solely on the basis of that license or certification.

The BHO has a process for notifying individuals or groups of providers when they are not chosen

for participation in the network.



Strength

KCBHO’s credentialing and contract monitoring policy and procedure indicates the BHO reviews

applications and that providers who:

o serve high-risk populations or specialize in conditions that require costly treatment will not be

discriminated against by KCBHO in its application review process

o are acting within the scope of their license or certification under applicable State law shall not

be discriminated against by KCBHO in its application review process with regard to the

provider’s participation, reimbursement, or indemnification based solely on that license or

certification.

Excluded Providers: 438.214 (d)

Scoring Criteria

The BHO has a policy and procedure to ensure the BHO does not employ or contract with

providers excluded from participation in federal healthcare programs.

The BHO can demonstrate the process and the documentation to determine whether individuals

or organizations are excluded providers.

The BHO ensures it is not employing or appointing on the governing board a person with

beneficial ownership of more than five percent of the BHO’s equity.

The BHO's provider contracts include the provision that providers do not knowingly have a

director, officer, partner, or other person excluded from participation in federal healthcare

programs with a beneficial ownership of more than five percent of the agency's equity.



37 Compliance







KCBHO needs to ensure the BHO as well as the BHAs are performing exclusion checks on a



38 Compliance


Table B-6: Summary of Compliance Review for Subcontractual Relationships and Delegation


Subcontractual Relationships and Delegation

Subcontractual Relationships and

Delegation

438.230 (a–c) ● Partially Met (pass)

Subcontractual Relationships and Delegation: 438.230 (a–c)

Scoring Criteria

The BHO has policies and procedures for oversight and accountability for any functions and

responsibilities it delegates to its subcontractors/BHAs.

The BHO performs pre-delegation assessments of contracted BHAs before delegation is granted

on the subcontractor's ability to perform the activities to be delegated.

The BHO has written contracts/agreements that address the specifics of the activities that have

been delegated to the subcontractor/BHA.

The BHO monitors the subcontractor's performance on an ongoing basis and subjects it to formal

review according to a periodic schedule established by the State, consistent with industry

standards or State laws and regulations.

The BHO includes in the delegation contract/agreement that the BHO is responsible for monitoring

and reviewing the subcontractor's/BHA's performance on an ongoing basis and provides criteria

for revoking delegation or imposing other sanctions if the subcontractor's performance is

inadequate.

The BHO initiates a corrective action if subcontractor/BHA performance does not meet industry

standards and/or requirements in the delegation or contract agreement.

The BHO follows up on any corrective action plan given to its subcontractor to ensure it has met

the criteria and, if the criteria is not met, imposes further corrective action, including revoking the

delegated activity.

The BHO requires the BHAs to follow the same CFR criteria for any services the BHAs delegate to

other entities.

The BHO monitors the BHAs’ delegated agreements with other entities.



Strengths

The BHO monitors delegated services of its BHAs and their delegates and assigns CAPs when

appropriate. KCBHO provided evidence that the BHO follows through on the CAPs it assigns to

its BHAs.

KCBHO maintains a matrix of all delegated functions and has effective mechanisms to monitor

the performance of those functions.



delegated services.

39 Compliance

KCBHO needs to add language to its BHA contracts that clarifies that BHA subcontractors are



KCBHO needs to add delegation monitoring to its annual QA evaluation.

40 Compliance


Table B-7: Summary of Compliance Review for Practice Guidelines


Practice Guidelines

Adoption of Practice Guidelines 438.236 (a–b) ● Fully Met (pass)

Dissemination of Guidelines 438.236 (c) ● Not Met (fail)

Application of Guidelines 438.236 (d) ● Fully Met (pass)


Adoption of Practice Guidelines: 438.236 (a–b)

Scoring Criteria

The BHO has documented policies and procedures related to adoption of practice guidelines,

including consultation with contracting healthcare professionals.

The BHO’s guidelines are based on valid and reliable clinical evidence or a consensus of

healthcare professionals in the particular field.

The BHO has documentation of its enrollees’ needs and how the guidelines fit those needs.

The BHO has documentation that the guidelines are reviewed and updated yearly.

The BHO has a documented policy and procedure for how affiliated BHAs are consulted as

guidelines are adopted and re-evaluated.



Strengths

KCBHO has imbedded its practice guidelines selection criteria in its policy Quality Management

of the King County Behavioral Health Organization Plan, Including Extraordinary Occurrences.

KCBHO has several practice guidelines, including:

o Diagnosis-Specific Practice Guidelines

o Children’s Wraparound Practice Guidelines

o Developmental Practice Guidelines for Children ages 0–21

o Practice Protocols for Recovery and Resiliency

KCBHO has been meeting with its BHAs to discuss the development of a co-occurring disorder

(COD) treatment guideline to meet the needs of its enrollees who have a COD diagnosis. The

guideline has been reviewed at KCBHO’s Clinical Directors Group and is still in its early stages.

41 Compliance

Dissemination of Guidelines: 438.236 (c)

Scoring Criteria

The BHO has a policy and procedure on how to disseminate practice guidelines to all providers

and, upon request, to enrollees and potential enrollees.

The BHO can demonstrate it has disseminated the practice guidelines to all BHAs and to

enrollees upon request.


● Not Met (fail)


Although KCBHO posts its practice guidelines on its website, they are not easy to locate. The titles are

not self-explanatory, and the guidelines are filed in the Quality Management and Extraordinary

Occurrences section of the website as appendices, which could make it very difficult for enrollees and

providers to access them.

KCBHO should consider including “practice guidelines” in the title of the practice guidelines

located on the BHO’s website in order to make them easily identifiable for both enrollees and

providers.




KCBHO needs to include in its policy the mechanism and frequency with which it distributes the


Application of Guidelines: 438.236 (d)

Scoring Criteria

The BHO has documented policies and procedures as well as documented meeting minutes

demonstrating that decisions for utilization management, enrollee education, coverage of services,

and other areas to which the guidelines apply are consistent with the guidelines.

The BHO annually monitors the effective use of practice guidelines by the BHAs.

The BHO has documentation of the interface process between the QAPI program and the practice

guidelines adoption process.



Strength

KCBHO audits the effective use of practice guidelines by the BHAs by monitoring extraordinary

occurrences, appeals, client concerns and grievances, authorization requests, case

consultations, and results of contract compliance site visits and record reviews.

42 Compliance


Table B-9: Summary of Compliance Review for Health Information Systems


Heath Information Systems

General Rule, Utilization, Claims, Grievances

and Appeals, and Disenrollments

438.242 (a) ● Fully Met (pass)

Basic Elements and Enrollee Encounter Data 438.242 (b),(c) ● Not Met (fail)


General Rule, Utilization, Claims, Grievances and Appeals, and Disenrollments:

438.242 (a)

Scoring Criteria

The BHO has a health information system that collects, analyzes, integrates, and reports data on

utilization, dis-enrollments, requests to change providers, grievances, and appeals.

The BHO utilizes reports from health information data to make informed management decisions.

The BHO uses the information it has collected and analyzed to identify trends in areas including

but not limited to utilization, grievances and appeals, dis-enrollments, and requests to change

providers.

The BHO analyzes the health information data to identify services needed for enrollees.



Strength

KCBHO monitors the reports produced by the IT department to review access to care standards,

analyze services by diagnosis, review inpatient and outpatient length of stay, study frequency of

opioid treatment services and the service utilization of high-intensity programs, and conduct

studies on over- and underutilization of services.

Basic Elements and Enrollee Encounter Data: 438.242 (b),(c)

Scoring Criteria

The BHO collects data on service encounters and on all provider and enrollee characteristics

included in the Consumer Information System (CIS) Data Dictionary.

The BHO ensures that data received from providers are accurate and complete by collecting data

in standardized formats and reviewing the data for accuracy, timeliness, completeness, logic, and

consistency.

The BHO certifies the data received from the BHAs.

The BHO makes all collected data available to the State and, upon request, to CMS.


● Not Met (fail)

43 Compliance




The BHO needs to create and implement a policy and procedure to ensure its BHAs are checking






letters






KCBHO needs to continue to train and assist its SUD treatment BHAs to ensure the BHAs can


44 Compliance

Section 8: Quality Assessment and Performance Improvement

Program

Table B-8: Summary of Compliance Review for Quality Assessment and Performance

Improvement Program

General Rules: 438.330 (a)

Scoring Criteria

The BHO has an ongoing quality assessment and performance improvement program (QAPI) for

the services it furnishes to its enrollees.

The BHO has a written QAPI program.

The BHO has a QA and PI process to evaluate the QAPI program and updates its annual plan.

The BHO collects, analyzes, and uses performance data to support its quality assessment and

performance improvement program.

The BHO has a Quality Management Committee that meets regularly, reviews results of

performance data, and reports to the governing board.

The BHO has effective mechanisms to assess the quality and appropriateness of care furnished to

enrollees.

The BHO conducts one clinical performance improvement project, one substance use disorder

performance improvement project, and one non-clinical performance improvement project each

year, one of which is a children-focused performance improvement project.

The BHO ensures its compliance with the State’s quality strategy plan.



Strengths

KCBHO developed and implemented its quality management plan for the integration of mental

health and SUD treatment services as a BHO effective April 1, 2016. The plan was reviewed by

the King County Behavioral Health Advisory Board, providers, and other stakeholders and is

monitored and revised by the KCBHO Quality Improvement Committee as needed.


Quality Assessment and Performance Improvement Program

General Rules 438.330 (a) ● Partially Met (pass)

Basic Elements 438.330 (b)(1–4) ● Partially Met (pass)

Performance Measurement 438.330 (c) ● Fully Met (pass)

Performance Improvement Projects 438.330 (d)(1–3) ● Fully Met (pass)

Program Review by the State 438.330 (e) ● Fully Met (pass)


45 Compliance

KCBHO monitors its contracted BHAs’ performance on the delivery of services through various

mechanisms to ensure quality care is provided to enrollees, delivery of appropriate services is

continued, and adherence to contract requirements is maintained. Trends that develop for

individual providers and on a system-wide level are analyzed and reported. Areas monitored at

least annually include:

o access

o service availability

o PIHP penetration

o service utilization

o provider caseloads and specialties

KCBHO’s contract monitoring staff provide technical assistance and work with individual

providers to address specific performance issues. Continued inability to meet performance

expectations and/ or comply with corrective actions may lead to further sanctions and ultimately

contribute to a decision by KCBHO not to re-credential the provider.

KCBHO maintains individual provider files, including correspondence, credentialing, and

grievance/complaint information.


KCBHO does not comply with the State Quality Strategy as the State does not have a current quality

strategy.

KCBHO will need to comply with the State Quality Strategy once the State has developed and

implemented its plan.

Basic Elements: 438.330 (b)(1–4)

Scoring Criteria



The BHO reports performance data to the State every year.

The BHO has a documented policy and procedure regarding the detection of both underutilization

and overutilization of services in all its programs.

The BHO has consistent criteria for identifying underutilization and overutilization.

The BHO has processes for routine monitoring of underutilization and overutilization.

The BHO has processes for taking corrective action to address underutilization and overutilization.



Strength

As a key component of its quality management program, King County BHO routinely monitors a

comprehensive set of process and outcome indicators.



State.

46 Compliance

KCBHO needs to continue to monitor and support its SUD treatment BHAs in order to ensure it


Performance Measurement: 438.330 (c)

Scoring Criteria

The BHO has a process in place to assess the standard performance measures.

The BHO measures and reports to the State on its performance, using the standard measures

required by the State.

The BHO has processes to submit data to DBHR, which enables the State to calculate the BHO’s

performance using standard measures.



Meets Criteria

Performance Improvement Projects: 438.330 (d)(1–3)

Scoring Criteria

The BHO has a process in place to assess the quality and appropriateness of care furnished to

enrollees.

The BHO monitors and tracks the quality and appropriateness of care furnished to enrollees.

The BHO has processes for taking action when quality and appropriateness of care issues are

identified.



Meets Criteria

Program Review by the State: 438.330 (e)

Scoring Criteria

The BHO has a process in place to submit its QAPI program evaluation to the State at least

annually.

The BHO monitors and tracks its required performance measures.

The BHO has processes to report outcomes and trended results of its performance improvement

projects.

The BHO has a process in place to evaluate the impact and effectiveness of its own QAPI

program.



Strength

The BHO is in the process of finalizing its evaluation of its program for 2016.

47 Performance Improvement Project Validation

Performance Improvement Project (PIP) Validation

Performance improvement projects (PIPs) are designed to assess and improve the processes and

outcomes of the healthcare system. They represent a focused effort to address a particular problem

identified by an organization. As prepaid inpatient health plans (PIHPs), Behavioral Health Organizations

(BHOs) are required to have an ongoing program of PIPs. BHOs must maintain one PIP each in clinical,

non-clinical, and substance use disorder (SUD)-focused areas (one of which must also include a child

focus). The PIPs must involve:

measurement of performance using objective quality indicators

implementation of systems interventions to achieve improvement in quality

evaluation of the effectiveness of the interventions

planning and initiation of activities for increasing or sustaining improvement

As a mandatory EQR activity, Qualis Health evaluates the BHOs’ PIPs to determine whether they are

designed, conducted, and reported in a methodologically sound manner. The PIPs must be designed to

achieve, through ongoing measurements and intervention in clinical and non-clinical areas, significant

improvement sustained over time that is expected to have a favorable effect on health outcomes and

enrollee satisfaction. In evaluating PIPs, Qualis Health determines whether

the study topic was appropriately selected

the study question is clear, simple, and answerable

the study population is appropriate and clearly defined

the study indicator is clearly defined and is adequate to answer the study question

the PIP’s sampling methods are appropriate and valid

the procedures the BHO used to collect the data to be analyzed for the PIP measurement(s) are

valid

the BHO’s plan for analyzing and interpreting PIP results is accurate

the BHO’s strategy for achieving real, sustained improvement(s) is appropriate

it is likely that the results of the PIP are accurate and that improvement is “real”

improvement is sustained over time

Following PIP evaluations, BHOs are offered technical assistance to improve their PIP study methodology

and outcomes. BHOs may resubmit their PIPs up to two weeks following the initial evaluation. PIPs are

assigned a final score following the final submission.

PIP Scoring

Qualis Health assessed the BHOs’ PIPs using the current CMS EQR protocol, available here:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-

External-Quality-Review.html.

Qualis Health assigns a score of “Met,” “Partially Met,” or “Not Met” to each of the 10 evaluation

components that are applicable to the performance improvement project being evaluated. Components

may be “Not Applicable” if the performance improvement project is at an early stage of implementation.

Components determined to be “Not Applicable” are not reviewed and are not included in the final scoring.

Scoring is based on the answers BHOs provide in the completion of a response form, which address


questions listed under each evaluation component, following a review of written documentation and in-

person interviews. Opportunities for improvement, technical assistance, and recommendations requiring a

corrective action plan (CAP) are provided for each standard.

The table below presents the scoring key for the PIP standards.

Scoring Icon Key

●Fully Met (pass) ●Partially Met (pass) ●Not Met (fail) ●N/A (not applicable)

PIP Validity and Reliability

Qualis Health assesses the overall validity and reliability of the reported results for all PIPs. Because

determining potential issues with the validity and reliability of the PIP is sometimes a judgment call, Qualis

Health reports a level of confidence in the study findings based on a global assessment of study design,

development, and implementation. Levels of confidence and their definitions are included in Table C-2.

Table C-1: Performance Improvement Project Validity and Reliability Confidence Levels

Confidence Level Definition

High confidence in reported results The study results are based on high-quality study design

and data collection and analysis procedures. The study

results are clearly valid and reliable.

Moderate confidence in reported

Results

The study design and data collection and analysis

procedures are not sufficient to warrant a higher level of

confidence. Study weaknesses (e.g., threats to internal or

external validity, barriers to implementation, questionable

study methodology) are identified that may impact the

validity and reliability or reported results.

Low confidence in reported results The study design and/or data collection and analysis

procedures are unlikely to result in valid and reliable study

results.

Not enough time has elapsed to

assess meaningful change

The PIP has not advanced to at least the first re-

measurement of the study indicator.


PIP Validation Results: Clinical PIP

Effectiveness of the Transitional Support Program

KCBHO is continuing its clinical PIP focused on the effectiveness of its Transitional Support Program

(TSP). The purpose of this PIP is to reduce the rate of psychiatric hospital readmissions and length of

stay to ultimately improve utilization and promote good clinical care by increasing focus on efficient and

effective discharge planning and strong connections and engagement in community-based outpatient

services. In 2016, the BHO demonstrated statistically significant improvement with both study indicators

(the number of psychiatric hospitalization admissions and the length of stay for those hospitalizations)

from the baseline measurement to the re-measurement period, one year prior to and one year post

enrollment in the Transitional Support Program. KCBHO reported that TSP staff were able to foster a

relationship between hospital discharge staff and outpatient mental health providers, which led to positive

outcomes as enrollees were able to stabilize in the community because of collaborative discharge

planning and transitional care.

Although the BHO was able to demonstrate sustained improvement through repeated measurements

over time, TSP staff have encountered difficulties implementing the TSP at two particular hospitals.

Throughout the study, TSP staff acknowledged various barriers and challenges working with several

hospitals, as some hospitals proved to be more collaborative than others. Some of these challenges

included difficulty for TSP staff in accessing enrollees and long wait times before access to the enrollee

was granted, struggles connecting with hospital social workers, hassles in obtaining discharge plans, and

lack of initiated contact from the hospital when enrollees were being discharged. In September 2016, the

BHO started regular transition planning meetings with all of the hospitals in the network to standardize

discharge planning practices. Because the two specified hospitals have the highest re-hospitalization

rates within the BHO network, the BHO is seeking to address the barriers and challenges of implementing

the TSP within those facilities. KCBHO is continuing this PIP with a specific focus on quality improvement

for the two hospitals. The BHO will continue to emphasize assisting hospital staff with assessment,

discharge planning, and care coordination of involuntarily detained enrollees. Hence, KCBHO plans to

assess length of stay and readmissions (30-day and 90-day) for a second 12-month re-measurement

period and monitor the proportion of admissions/detentions by hospital.

Study question: “whether the PIP intervention (TSP program) reduces the following 2 PIP indicators to a

statistically significant (p<.05) degree for the eligible PIP (TSP) population:

(1) the average length-of-stay of the hospitalizations in the year following the first TSP service compared

to the average length-of-stay of hospitalizations during the prior year

(2) the average number of hospitalizations in the year following the first TSP service compared to the year

prior to first TSP service.”

Dates of study period:

The baseline period will cover the target population's hospitalizations during the year prior to TSP

enrollment in the date range of July 1, 2013, through March 30, 2015. For example, if a person enrolled in

a TSP on July 1, 2014, their baseline measurement year would be July 1, 2013, through June 30, 2014,

whereas a person enrolled March 31, 2015, would have a baseline year of March 31, 2014, through

March 30, 2015.

The re-measurement period will cover the target population's hospitalization during the year following the

detention in which TSP enrollment occurs. For example, if a person was enrolled in a TSP on July 1,


2014, their re-measurement year would begin as soon as they were discharged from that episode of

detention. If the person was discharged on July 2, 2014, the re-measurement period would be July 2,

2014, through July 1, 2015.

An additional re-measurement period will include an analysis extending the re-measurement period to a

second year following the detention in which TSP enrollment occurred to determine if improvements were

sustained over time through March 31, 2017. KCBHO is seeking to review the variation between hospitals

and determine whether the two hospitals with high barriers to access and high re-hospitalization rates

have improved from year one post- to year two post-first TSP service. Furthermore, the BHO will also

assess the TSP enrollment rate.

(KCBHO did not provide a specific study end date; Qualis Health recommended during the on-site review

that KCBHO implement the new intervention with the two hospitals identified and then retire the PIP in

2017.)

Table C-2: Clinical PIP Validation Results

Study Design

Activity

SCORE

Design 1 Appropriate study topic ● Partially Met (pass)

2 Clearly defined, answerable study question ● Partially Met (pass)

3 Correctly identified study population ● Fully Met (pass)

4 Correctly identified study indicator ● Fully Met (pass)

Implementation 5 Valid sampling technique ●N/A

6 Accurate/complete data collection ● Fully Met (pass)

7 Appropriate data analysis/

interpretation of study results ● Fully Met (pass)

Outcomes 8 Appropriate improvement strategies ● Fully Met (pass)

9 Real improvement achieved ●N/A

10 Sustained improvement achieved ●N/A

Overall Score

Confidence Level:

High confidence in reported results


Reviewer Comments:

KCBHO previously completed a rendition of this PIP but identified barriers and challenges with

implementing the Transitional Support Program in two specific hospitals. As a result, the BHO


recognized the need to continue its evaluation activities and quality improvement efforts to increase TSP

penetration rates and lower psychiatric readmissions at these facilities. KCBHO identified these two

hospitals as also having the highest re-hospitalization rates within the provider network. High numbers

of potentially preventable events can indicate deficiencies in quality of care. The BHO should implement

its new strategy at these facilities and then retire the PIP in its current format. As KCBHO monitors these

interventions, it is important to pay close attention to the organizational change process and the degree

to which it is affecting the specific intervention. During implementation, the BHO and key stakeholders

should make several checks to ensure that the hospitals are successfully integrating the changes.

Further, once the re-measurement is complete, if rates remain suboptimal, the BHO should continue its

efforts internally.

Standard 1: Selected Study Topic Is Relevant and Prioritized

Table C-3: Validation of PIP Selected Study Topic

Criterion Description Result

1.1 The study topic was selected through a comprehensive process

that involved data collection and analysis of enrollee needs,

care, and services.


Reviewer Comments:

The study topic was selected after a review of KCBHO data related to involuntary hospitalizations and

readmission rates. There was no review of national or state data or of historical trends related to this issue.

KCBHO’s initial reasoning for pursuing this PIP was based on a 10-year decline in King County and

statewide in inpatient psychiatric hospital beds. The BHO focused its efforts on addressing the need to

reduce psychiatric hospital readmissions and lengths of stay with the use of the Transitional Support

Program. TSP goals are to improve enrollee transitions from the inpatient hospital setting to other care

settings, overall improving the quality of care. KCBHO later identified a need to continue this PIP as a

result of the distinct barriers and challenges the TSP team faced when working with two particular

hospitals.

1.2 The PIP is consistent with the demographics and epidemiology

of the enrollees. ●Not Met (fail)

Reviewer Comments:

KCBHO has not updated its data to demonstrate that this PIP is still consistent with the demographics and

epidemiology of the enrollees. The BHO presented the same enrollee data as during the 2016 EQR, which

consisted of demographics from July 2013 to June 2014. During this timeframe, King County crisis and

commitment staff administered 3,194 detentions; of these 1,391 were Medicaid-enrolled adults over the

age of 18 at the time of their hospital admission or within 90 days of discharge.

1.3 Input from enrollees, family members, peers, and/or advocates

was considered during the selection of the PIP. ● Fully Met (pass)

Reviewer Comments:

At the onset of this PIP, KCBHO solicited input from numerous stakeholders, including community hospital

staff, inclusive of social workers and utilization review coordinators, the King County Clinical Director’s

group, provider agency CEOs, and the internal RSN Quality Improvement Group. The BHO also sought

peer involvement to gain an understanding of how the use of peers can be beneficial to hospital discharge

assistance and outpatient engagement.

For the continuation of the PIP, King County BHO and the Transitional Support Program team held

meetings with hospital administrators and conducted a Prevention Task Force meeting, and the BHO


medical director chaired meetings with the clinical directors as well as hospital leadership.

1.4 The PIP addresses a broad spectrum of key aspects of enrollee

care and services. ● Fully Met (pass)

Reviewer Comments:

This PIP addresses a specified high-need subpopulation as identified by KCBHO. The BHO believes

enrollees who become involuntarily detained due to danger to themselves or others who are gravely

disabled and are not already engaged in outpatient services have the greatest need. The strategies are

expected to impact a broad range of enrollee care and services by bringing forth more effective and

efficient care management approaches to stabilize the hospitalized enrollee quickly, hence reducing the

lengths of stay and rates of psychiatric hospital readmissions.

Opportunity for Improvement:

KCBHO did not provide updated data on enrollee demographics and epidemiology. Per CMS, the topic

should be “consistent with demographic and epidemiologic information of the current enrollees.”

KCBHO needs to provide current and relevant data on enrollee demographics and epidemiology.

Standard 2: Study Question Is Clearly Defined

Table C-4: Validation of PIP Study Question


2.1 The study question(s) is clear, concise, and answerable. ●Not Met (fail)

Reviewer Comments:

KCBHO states it is assessing “whether the PIP intervention (TSP program) reduces the following 2 PIP

indicators to a statistically significant (p<.05) degree for the eligible PIP (TSP) population:

(1) the average length-of-stay of the hospitalizations in the year following the first TSP service compared

to the average length-of-stay of hospitalizations during the prior year

(2) the average number of hospitalizations in the year following the first TSP service compared to the year

prior to first TSP service”

The BHO did not construct its study question in the form of a question, but instead created statements

regarding potential outcomes of the intervention.

2.2 The study question sets the framework for goals, data

collection, analysis, and interpretation. ● Fully Met (pass)

Reviewer Comments:

The statements identify the focus of the PIP and set the framework for study aims, as well as for collecting

and analyzing the data.

2.3 The study question includes the intervention, the study

population (denominator), what is being measured (numerator),

a metric (percent or average), and a desired outcome.


Reviewer Comments:

KCBHO describes the intervention as the Transitional Support Program. The study population is defined

as Medicaid enrollees, who are at least 18 years old, who are involuntarily detained at one of the two

identified hospitals and not successfully engaged in outpatient mental health services. One numerator is

the average difference in individual lengths of stay one year before and one year after initiation of TSP

enrollment. The second numerator is the average of the differences for each enrollee between the number


of hospitalizations before and after the start of enrollment in the TSP. The metric and the desired outcome

for both indicators reduce the indicators by a statistically significant degree, p<.05.

Recommendation Requiring CAP:

Per the EQR Protocol 3: Validating Performance Improvement Projects, version 2.0, September 2012, the

criteria for determining the adequacy of the study question is The study question(s) should be clear,

simple, and answerable. In addition, they should be stated in a way that supports the ability to determine

whether the intervention has a measurable impact for a clearly defined population.

KCBHO did not state the focus of its study in the form of a question. While the BHO does provide

statements describing what it plans to achieve through the intervention, it is not posed in a clear, simple,

and answerable format.

KCBHO needs to formulate a study question that is truly in the structure of a question.

Standard 3: Study Population Is Clearly Defined, and, if a Sample Is Used, Appropriate

Methodology Is Used

Table C-5: Validation of PIP Study Population


3.1 The enrollee population to whom the study question and indicator

are relevant is clearly defined. ● Fully Met (pass)

Reviewer Comments:

The study population is defined as Medicaid enrollees served by a TSP at the two hospitals from July 1,

2014, to March 31, 2017. In order to be served by a TSP, an enrollee must be at least 18 years old,

involuntarily committed to a community psychiatric hospital, and not successfully engaged in outpatient

publicly funded mental health services. Not engaged is defined as having fewer than six hours of

outpatient service in the previous 60 days.

3.2 The inclusion or exclusion criterion, if applicable, is clearly

defined. ●N/A

Reviewer Comments:

KCBHO notes that there is no formal inclusion or exclusion criterion.

3.3 The study population is reflective of the entire Medicaid enrollee

population to which the study indicator applies, or a sample is

used.


Reviewer Comments:

KCBHO’s defined study population is the same as the Medicaid enrollee population to which the study

indicator applies.

3.4 Data collection approaches ensured all required information was

captured for all enrollees to whom the study question applied. ● Fully Met (pass)

Reviewer Comments:

All study population data are recorded in KCBHO’s electronic management information system (MIS). All

Medicaid enrollee TSP authorizations, lengths of stay, admissions, and discharges to psychiatric hospitals

are documented in the MIS. Additionally, KCBHO reports that DBHR data regarding admissions and

discharges from the state hospital are routinely updated. Medicaid eligibility files are received monthly from

the State.

Meets Criteria


Standard 4: Study Indicator Is Objective and Measureable

Table C-6: Validation of PIP Study Indicator


4.1 The study includes a clear description of the study indicator(s) and

clearly defined numerator and denominator. ● Fully Met (pass)

Reviewer Comments:

KCBHO will continue to study the original two PIP indicators—the annual average length of stay of

hospitalizations and annual average number of hospitalizations for an individual enrolled in a TSP at the

two hospitals. Additionally, the BHO will examine the rate of TSP enrollment by hospital over time from

July 1, 2014, to March 31, 2017, in six-month intervals.

The numerator is the number of TSP authorizations in a given six-month time period.

The denominator is the number of detentions for that time period.

4.2 The study includes an explanation of how the indicators are

appropriate and adequate to answer the study question, and

describes how the indicator objectively measures change to

impact the enrollee.


Reviewer Comments:

The original PIP study indicators, average length of stay for psychiatric hospitalizations and number of

psychiatric hospitalizations pre and post intervention, as well as the new indicator, TSP enrollment by

hospital over time, measure change in a clear manner. All indicators are unbiased quantitative measures

that can assess the impact of the Transitional Support Program on enrollees.

4.3 There is a clear and realistic plan that includes where and how the

data on the indicator are collected, all of the elements of the data

collection plan are in place and viable, and mitigation strategies

are in place in case sufficient data are not able to be collected.


Reviewer Comments:

KCBHO is capturing all data relevant to this PIP in its MIS. This includes all Medicaid enrollee TSP

authorizations, hospital admissions, and discharges. Data obtained from DBHR regarding enrollees who

have been hospitalized in the state hospital are routinely integrated into the MIS.

4.4 The baseline and first and second re-measurement periods are

unambiguously stated and appropriate in length. ● Fully Met (pass)

Reviewer Comments:

The measurement periods are articulated in a manner that is clear and unambiguous:

The baseline period covers the study population's hospitalizations during the year prior to TSP enrollment,

sometime between July 1, 2013, and March 30, 2015. For example, an individual enrolled in a TSP on July

1, 2014, would have a baseline year of July 1, 2013, through June 30, 2014; a person enrolled on March

31, 2015, would have a baseline year of March 31, 2014, through March 30, 2015.

Re-measurement periods covered the target population's hospitalizations during the year following the

detention in which TSP enrollment occurred, i.e., July 2, 2014, through March 3, 2016. For example, an

individual enrolled in a TSP on July 1, 2014, would have a re-measurement period upon discharge from

the hospital, which could be July 2, 2014, through July 1, 2015; a person enrolled in TSP on March 31,

2015, would have a re-measurement year of April 1, 2015, through March 31, 2016.


An additional re-measurement period will include an analysis extending the re-measurement period to a

second year following the detention in which TSP enrollment occurred to determine whether improvements

were sustained over time through March 31, 2017. KCBHO is seeking to review the variation between

hospitals and find whether the two hospitals with high barriers to access and high re-hospitalization rates

have improved from year one post- to year two post-first TSP service.

Meets Criteria

Standard 5: Sampling Method

Table C-7: Validation of PIP Sampling Methods


5.1 The method for defining and calculating the sample

size, the true and estimated frequency of the event, the

confidence level, and the acceptable margin error are

specified and clearly stated.

●N/A

Reviewer Comments:

Not applicable; no sampling was used for this PIP.

5.2 The sampling technique is described, and whether the

sample is a probability or non-probability sample is

specified.

●N/A

Reviewer Comments:


5.3 Valid sampling techniques are employed to protect

against bias. ●N/A

Reviewer Comments:


5.4 The sample contains a sufficient number of enrollees. ●N/A

Reviewer Comments:


N/A

Standard 6: Data Collection Procedure

Table C-8: Validation of PIP Data Collection Procedures


6.1 The study design clearly specifies the data to be collected. ● Fully Met (pass)

Reviewer Comments:

KCBHO plans to conduct an assessment of performance improvement efforts at the two identified

hospitals, which were initiated as a result of the barriers to hospitalized enrollee access and coordinated

discharge planning. To complete this assessment, KCBHO will examine the study indicators (the number


of psychiatric hospitalization admissions and the length of stay for those hospitalizations) as well as the

TSP enrollment rate (number of TSP enrolled/total detentions) by hospital and look for improvement over

time in six-month intervals, particularly for the two hospitals with the highest re-hospitalization rates in the

first 12 months of TSP service. This PIP focuses on Medicaid enrollees who are Medicaid eligible at the

time of admission into the hospital or within 90 days of discharge. TSP enrollment is defined as an

individual who is at least 18 years old and has a TSP program authorization in KCBHO’s MIS.

6.2 The study design clearly specifies the sources of data. ● Fully Met (pass)

Reviewer Comments:

Medicaid enrollment is determined from Medicaid eligibility files received from the State on a monthly basis

and incorporated into the BHO’s MIS. TSP authorizations, psychiatric hospitalization admissions by type,

voluntary or involuntary, and hospital discharges are captured in the MIS. Additional information regarding

hospitalizations in the state hospital is routinely gathered from DBHR and integrated into the MIS.

6.3 The study design includes a description of the data collection

methods used, including the types of data collected, an

explanation of how the methods elicit valid and reliable data, the

intervals at which the data will be collected and, if HEDIS or other

formal methodology is used, a description of the process.


Reviewer Comments:

KCBHO’s data collection is automated electronically. Medicaid eligibility is downloaded from the State to

the BHO’s MIS on a monthly basis using an automatic process. TSP enrollment data are uploaded to the

BHO’s MIS by the provider agency on a nightly basis. On a monthly basis, validation of TSP enrollment

occurs by comparing monthly caseload reports sent to the BHO by the provider with the information in the

MIS. Study indicator data are uploaded on a nightly basis to the MIS from the hospital and the crisis clinic.

State hospital data are downloaded into the BHO’s MIS each night. BHO staff reconcile hospital data with

State payment data monthly in order to validate the accuracy the data.

6.4 The study design includes a description of the instruments used

for data collection, including a narrative regarding how the

instrument provides for consistent and accurate data collection

over the time periods studied. If any additional documentation was

requested, it was provided and appropriate.


Reviewer Comments:

All data necessary for this PIP are maintained in KCBHO’s MIS. A query based on MIS program

authorization pulls data on the TSP population, including Medicaid status. Baseline and re-measurement

hospitalization information for the specified population is also sorted. A Fourth Generation Programming

Language (4GL) code is used to extract the data. KCBHO provided a copy of the query used to extract the

data.

6.5 The study states who will be collecting the data, and includes their

qualifications to collect the data. ● Fully Met (pass)

Reviewer Comments:

KCBHO staff involved in collecting the data elements include a King County senior application developer

with King County IT, who has over a decade of programming experience. This individual extracts the data

from KCBHO’s MIS.

The initial data analysis steps were completed by a past KCBHO program evaluator who held a PhD in

psychology and had over 20 years of clinical research, program evaluation, and quality improvement

experience.


The repeat analysis will be completed by KCBHO’s current performance measurement evaluator, who

holds a PhD in health services research and has over 15 years of research, program evaluation, and

quality improvement experience.

6.6 The study includes a description of how inter-rater reliability is

ensured. ●N/A

Reviewer Comments:

Not applicable; this PIP uses only administrative data.

Meets Criteria

Standard 7: Data Analysis and Interpretation of Study Results

Table C-9: Validation of PIP Data Analysis and Interpretation


7.1 There is a clear description of the data analysis plan that includes

the type of statistical analysis used and the confidence level, and

the analysis was performed according to the plan.


Reviewer Comments:

The BHO plans to use paired two-tailed t-tests to analyze the data for both indicators. For each participant,

the number of psychiatric hospitalizations and lengths of stay pre and post intervention will be compared.

A p<.05 probability/confidence level will be used to assess statistical significance. The PIP has not

progressed to the point of data analysis and interpretation.

7.2 Numerical PIP results and findings are accurately and clearly

presented. ●N/A

Reviewer Comments:

The PIP has not progressed to the point of data analysis and interpretation.

7.3 The data analysis methodology is appropriate to the study question

and data types. ●N/A

Reviewer Comments:


7.4 The analysis identified statistical significance of differences

between initial and repeat measurements, and was performed

correctly.

●N/A

Reviewer Comments:


7.5 If threats to internal or external validity were identified, the potential

impact and resolution was explained. ●N/A

Reviewer Comments:


7.6 The analysis of study data includes an interpretation of the extent to

which the PIP was successful, statistically significant or otherwise,

as well as a description of follow-up activities.

●N/A

Reviewer Comments:


Technical Assistance:

Valid data interpretation occurs when the analysis is carried out as planned. Results should be displayed


in an easily understood format such as a table or graph with clear measurement periods, outcomes, and

other points of comparison clearly shown. The analysis should include a comparison of the initial and

repeat measurements, and any threats to validity should be noted. KCBHO should include in the

discussion whether progress toward the PIP’s goal was made and details regarding any follow-up actions.

Standard 8: Appropriate Improvement Strategies

Table C-10: Validation of PIP Improvement Strategies


8.1 Steps were taken to identify improvement opportunities during

the PIP process. ● Fully Met (pass)

Reviewer Comments:

Since the initiation and re-measurement periods of the PIP, KCBHO performed an analysis on the

challenges and barriers in working with hospitals identified by TSP staff. It was discovered that two

hospitals in particular posed the majority of challenges and perpetual barriers. These included difficulty

with physical access to hospitalized enrollees and long wait times (typically 30–45 minutes) before being

granted access to the enrollees; communication challenges with hospital social workers regarding the

coordination of discharge plans and referrals; difficulty obtaining discharge plans (especially those with

sufficient detail), medical records, or prescription information from these facilities; and lack of notification

by the hospital when an enrollee was being discharged. The BHO recognizes that deficient discharge

planning and care coordination can impact ongoing enrollee treatment and quality of care because these

enrollees are not connected to outpatient services and are further likely to have challenges obtaining

medications in an outpatient setting.

The Transitional Support Program team determined that there was a correlation between excessive

hospital administrative staff turnover and the shortage of information and awareness regarding the TSP.

As a result, TSP staff access to hospitalized enrollees was also hindered. The lack of discharge resources,

such as access to ProviderOne, which enables providers to look up enrollee Medicaid eligibility, was also

identified as a challenge.

8.2 Reasonable interventions were undertaken to address

causes/barriers identified through data analysis and QI

processes.


Reviewer Comments:

Through a thorough analysis of the identified improvement opportunities, KCBHO undertook many

interventions, specifically with the two hospitals that presented the most challenges with TSP access.

These facilities had the highest 90-day re-hospitalization rates as well. In an effort to enhance

collaboration, KCBHO met with the leadership of one of the hospitals and developed solutions that allowed

TSP staff to obtain quicker access to hospitalized enrollees; however, the staff were first required to

receive a flu vaccine and complete a TB test. Only a small number of the TSP staff agreed to these

stipulations. Additionally, the BHO staff began working together with King County hospitals on discharge

planning and relationship building. Although the TSP targets Medicaid enrollees and those eligible for

Medicaid, hospital staff at a few hospitals were unable to look up enrollees using ProviderOne due to lack

of access. KCBHO has remedied this by searching for individuals in ProviderOne to determine eligibility for

the Transitional Support Program.

TSP staff have also implemented some changes to enhance the PIP initiative. To increase knowledge and


awareness of the program, they launched a marketing campaign, which included brochures and providing

education to new hospital administrative staff. They have been able to form connections by strengthening

rapport with hospital administrative staff, which has aided in their ability to gain access to hospitalized

enrollees. Last, in the absence of discharge plans, TSP staff have been able to create enrollee transition

plans.

8.3 The interventions are/were sufficient to be expected to improve

processes or outcomes. ● Fully Met (pass)

Reviewer Comments:

The implementation of the identified solutions is expected to improve processes and outcomes for the

Transitional Support Program. KCBHO reports that it is still in the process of assessing the connection

between the TSP team and hospital discharge planners from these two hospitals.

8.4 The interventions are/were culturally and linguistically

appropriate. ● Fully Met (pass)

Reviewer Comments:

KCBHO’s Transitional Support Program is based on the Association for Professionals in Infection Control

and Epidemiology (APIC) and Coleman models of care. Both models were developed and used in

culturally diverse settings. Additionally, the BHO states that the TSP team works with its clients in a

linguistically and culturally appropriate manner by utilizing translators and cultural specialty workers as

needed. Members of the TSP team work with enrolled clients who have been discharged from the hospital

to link them to outpatient care and other kinds of 24-hour crisis services available within the BHO in order

to avoid re-hospitalization.

Meets Criteria

Standard 9: Assess Whether Improvement Is “Real” Improvement

Table C-11: Validation of PIP Improvement Assessment


9.1 The same methodology used for the baseline measurement was

used when measurement was repeated. ●N/A

Reviewer Comments:

Although the PIP has not progressed to the point at which improvement can be assessed, KCBHO has

indicated it will be using the same methodology for the second re-measurement period. Additionally, it will

conduct a data analysis by re-evaluating the baseline and the first re-measurement period data to ensure

that the methodology is consistent.

9.2 There is a description of the data analysis regarding improvements

in process or outcomes of care. ●N/A

Reviewer Comments:

The PIP has not progressed to the point at which improvement can be assessed.

9.3 There is an evaluation demonstrating that reported improvement in

performance appears to be the result of the planned quality

improvement intervention, or an analysis related to why there was

not improvement.

●N/A

Reviewer Comments:



9.4 There is statistical evidence that any observed performance

improvement is true improvement, and statistical analysis was

performed thoroughly and accurately.

●N/A

Reviewer Comments:



Whether a change does or does not occur, KCBHO must assess components of the PIP to determine

whether the change or lack of change is attributable to an event unrelated to the intervention, random

chance, or to the intervention. Evaluation of results is the focus of this step.

Standard 10: The BHO Has Sustained the Documented Improvement

Table C-12: Validation of PIP Sustained Improvement


10.1 Sustained improvement was demonstrated through repeated

measurements over comparable time periods. If improvement

was not sustained, there is an explanation and an indicated plan

for next steps.

●N/A

Reviewer Comments:

Once KCBHO has completed the implementation of the quality improvement efforts at the two hospitals, it

should be able to address this step. The ultimate goal with this step is to demonstrate that sustained

improvement is achieved. However, if improvement is not continual, an evaluation of the PIP needs to be

conducted, and the BHO will need to consider a plan for retirement.

N/A


PIP Validation Results: Non-Clinical Children’s PIP

Improved Coordination with Primary Care for Children and Youth

KCBHO is continuing its non-clinical PIP focused on improving coordination with primary care providers

for Medicaid children and adolescents.

Washington State’s Apple Health managed care organization (MCO) contracts set forth the requirement

that MCOs coordinate care for enrollees, including care coordination and data sharing between the MCOs

and the BHOs. With the implementation of this PIP, KCBHO seeks to better identify and coordinate care

for Medicaid youth dually enrolled with the BHO and Molina Healthcare Apple Health who have a high

utilization of acute care, whether medically or psychiatrically related. Previously, KCBHO sought to

conduct this PIP utilizing data from the five MCOs in the network; however, the BHO experienced difficulty

obtaining data from all of the MCOs. Thus, KCBHO is focusing its efforts on working with one MCO

(Molina) to ensure that care for their dually enrolled enrollees is coordinated, with an aim to make sure

these enrollees receive the right care at the right time, while avoiding unnecessary duplication of services.

The BHO has identified a care coordination process to improve enrollee care. This process includes 1)

identifying those with highest emergency department (ED) utilization and shared cases with Molina; 2)

identifying a treatment team; 3) selecting a lead entity (MCO or BHO) that develops initial care guidelines

for ED providers if the youth presents at an ED again; 4) if the youth presents at an ED, notifying the lead

(through the Emergency Department Information Exchange [EDIE]/PreManage system), who provides an

immediate response or intervention for the identified youth; 5) the lead coordinating with the team working

with the child/family to discuss the shared intervention plan; 6) the lead convening care coordination

meetings to agree on treatment goals, review gaps in care, collaborate around identified issues, and

develop a joint family-driven care plan. The intervention also includes an information systems component

of sharing the care plan and patient records on EDIE/PreManage for the BHO, the MCO, and providers to

access. BHO, MCO, emergency department staff and other treatment providers will be trained to check

the treatment plan on EDIE/PreManage when interacting with the youth and their family. KCBHO has

indicated it will implement this process with the other MCOs once it has deemed the new process

successful.

Study question:

“Does implementation of a BHO-MCO care coordination intervention* significantly reduce psychiatrically

related ED visits for Medicaid-enrolled children/youth (age <=18) in both ongoing outpatient BHO mental

health services and Molina Apple Healthcare and who had at least one psychiatrically related ED visit

during this period when comparing baseline to the re-measurement period?”

* The intervention is defined as being a shared case review and care coordination intervention with

Molina Healthcare Apple Health (including shared treatment plans on an information system accessible

by both the BHO/Molina and ER provider staff). The interventions may include Wraparound or CCORS

[Children’s Crisis Outreach Response System] (depending on the identified need).

Dates of study period:

Baseline measurement: December 1, 2015, through November 30, 2016

Re-measurement periods: September 2017, December 2017, and June 2018 (3, 6, and 12 months post

intervention)


Table C-13: Non-Clinical PIP Validation Results

Study Design

Activity

SCORE


2 Clearly defined, answerable study question ● Fully Met (pass)

3 Correctly identified study population ● Fully Met (pass)

4 Correctly identified study indicator ● Fully Met (pass)


6 Accurate/complete data collection ● Fully Met (pass)


interpretation of study results ●N/A

Outcomes 8 Appropriate improvement strategies ●N/A



Overall Score

Confidence Level:

Not enough time has elapsed to assess meaningful

change


Reviewer Comments:

Because of KCBHO’s difficulty in obtaining data from all five of the Apple Health MCOs, this PIP was in

a very early stage for several years. KCBHO has followed through on last year’s recommendation to

fully formulate and begin the PIP. With baseline measurement and re-measurement periods redefined,

KCBHO should be able to progress further with collecting, reporting, and analyzing the data for youth

dually enrolled in the BHO and Molina Healthcare Apple Health. KCBHO indicated it has now

succeeded in procuring the essential data from Medicaid eligibility files and EDIE/PreManage, allowing

the BHO to collect and analyze the information necessary to interpret whether the identified

interventions will achieve the desired outcomes.







care, and services.


Reviewer Comments:

This study topic focuses on improving processes and outcomes of healthcare provided by the BHO.

KCBHO selected this PIP through a comprehensive process, which involved discussions with numerous

stakeholders as well as review of acute care utilization for children and youth continuously enrolled in

outpatient, crisis, or hospital BHO services. The BHO also conducted an analysis of Molina Healthcare’s

Apple Health data. In assessing emergency department (ED) utilization for a period of six months, from

December 2014 to May 2015, the BHO found that of the 2,202 youth shared by the BHO and Molina

Healthcare Apple Health, 321 were involved in 443 ED events. Of the 443 ED events, 109 encounters

from 87 youth indicated a primary or secondary psychiatric diagnosis, translating to 25 percent of the

subpopulation having at least one psychiatrically related ED visit. KCBHO’s analysis of this data showed

that youth who were utilizing the emergency department were not having their needs met through routine

outpatient services. KCBHO determined this topic would be beneficial to pursue because it identifies a

group at particularly high risk of continued utilization and negative outcomes, and it dovetails with

healthcare integration efforts that afford new opportunities for identifying the population, coordinating care,

and tracking outcomes.


of the enrollees. ● Partially Met (pass)

Reviewer Comments:

KCBHO provided an initial data analysis for youth dually enrolled with the BHO and Molina. The data from

the date range of August 2015 through January 2016 showed that 113 MCO/BHO shared youth with a

psychiatric diagnosis or asthma had 160 ED visits. When assessing the needs of these youth, the BHO

found that 22 were already enrolled in BHO services.

The BHO solely reviewed data specific to individuals dually enrolled with KCBHO and Molina. It did not

include any overall local, state, or national data related to the study population. Based on the data that

were submitted, it is not clear whether the PIP is truly consistent with the demographics and healthcare

needs of King County’s enrollees.


was considered during the selection of the PIP. ● Fully Met (pass)

Reviewer Comments:

KCBHO held various discussions with relevant stakeholders before choosing this topic. The BHO’s Youth

Clinical Directors group and Parent Partner Network group provided input and noted that coordination

between BHAs and primary care providers was a challenge. The Parent Partner Network participants

indicated that parents and youth find it challenging to navigate the physical healthcare and mental health

systems, especially when a child has a psychiatric crisis or a medical issue that appears to be

psychiatrically related.


care and services. ● Fully Met (pass)

Reviewer Comments:

This study topic is meant to address high utilizers of acute care mental health services. The intervention


will focus on preventative care and care coordination, conducted with the hospital and outpatient systems,

to address this high-risk, high-need population.

Opportunity Improvement:

KCBHO did not provide updated data on enrollee demographics and epidemiology. Per CMS, the topic

should be “consistent with demographic and epidemiologic information of the current enrollees.”

KCBHO needs to provide current and relevant data on enrollee demographics and epidemiology.

This should include overall standardized local, state, or national data linked to the study

population.




2.1 The study question(s) is clear, concise, and answerable. ● Fully Met (pass)

Reviewer Comments:

KCBHO’s PIP study question is “Does implementation of a BHO-MCO care coordination intervention*

significantly reduce psychiatrically-related ED visits for Medicaid-enrolled children/youth (age <=18) in both

ongoing outpatient BHO mental health services and Molina Apple Healthcare and who had at least one

psychiatrically-related ED visit during this period when comparing baseline to the re-measurement

period?”

*The intervention is defined as being a shared case review and care coordination intervention with Molina

Healthcare Apple Health (including shared treatment plans on an information system accessible by both

the BHO/Molina and ER provider staff). The interventions may include Wraparound or CCORs (depending

on the identified need).

The study question is stated in a manner that is straightforward and answerable.


collection, analysis, and interpretation. ● Fully Met (pass)

Reviewer Comments:

The study question establishes a framework for the goal, data collection, and analysis of reducing ED

visits for Medicaid youth who are dually enrolled with KCBHO and Molina.





Reviewer Comments:

KCBHO has stated its intervention as a shared case review and care coordination with Molina (including

shared treatment plans on an information system accessible by both BHO/Molina and ER provider staff).

Additionally, the BHO may utilize Wraparound or CCORs (depending on the identified need of the

Medicaid enrollee).

The study population is defined as Medicaid-enrolled youth 18 years of age and younger who are

continuously enrolled in both outpatient, crisis, or hospital BHO services and Molina Healthcare’s Apple

Health plan who have had the highest amount of hospital ED use—typically five or more ED visits per

year.


The numerator is the average difference in the matched scores from baseline to re-measurement. This is

calculated by measuring the sum of the difference in the number of ED visits for the measurement periods

before and after the intervention divided by the total number of enrollees with pre- and post-intervention

measurement scores.

The denominator is the total number of individuals with pre- and post-measurement scores.

Meets Criteria

Standard 3: Study Population Is Clearly Defined, and, if a Sample is Used, Appropriate

Methodology Is Used




are relevant is clearly defined. ● Fully Met (pass)

Reviewer Comments:

KCBHO has defined the study population as Medicaid-enrolled youth 18 years of age and younger who

are continuously enrolled in both outpatient, crisis, or hospital BHO services and Molina Healthcare’s

Apple Health plan from November 2015 through November 2016 who have had the highest amount of ED

use during this time period (typically five or more ED visits per year).

3.2 The inclusion or exclusion criterion, if applicable, is clearly defined. ● Fully Met (pass)

Reviewer Comments:

KCBHO had previously defined the criterion as “psychiatrically related” ED visits, which meant a visit in

which an individual receives a primary or secondary psychiatric diagnosis, including DSM codes 290–390

(ICD-10 codes starting with F) or asthma code J450505. This criterion has been removed from the

description of the PIP study population.

No exclusions were reported.


population to which the study indicator applies, or a sample is used. ● Fully Met (pass)

Reviewer Comments:

The study population and the Medicaid enrollee population are the same.


captured for all enrollees to whom the study question applied. ● Fully Met (pass)

Reviewer Comments:

KCBHO reported that the data sources used to identify the PIP study population included two sets of

administrative data: Medicaid eligibility files and Emergency Department Information Exchange

(EDIE)/PreManage.

Medicaid eligibility files are obtained by the BHO from DBHR on a monthly basis. These files contain all

Medicaid-enrolled individuals for a given month, the BHO they are affiliated with, and the MCO in which

the individual enrolled. The BHO will look expressly at individuals enrolled with Molina.


EDIE/PreManage contains hospital ED utilization data across the state of Washington. It identifies and

provides information on high-risk patients in real time. It is also a web-based communication tool to assist

with care coordination between different systems of healthcare.

A file of shared King County BHO-MCO clients is uploaded to EDIE/PreManage monthly, and reports can

be generated for the Molina-BHO clients.

Meets Criteria





clearly defined numerator and denominator. ● Fully Met (pass)

Reviewer Comments:

The study indicator for this PIP is the change in the number of ED visits for the PIP study population.

The numerator is the average difference in the matched scores from baseline to re-measurement. This is

calculated by measuring the sum of the difference in the number of ED visits for the measurement periods

before and after the intervention divided by the total number of enrollees with pre- and post-intervention

measurement scores.

The denominator is the total number of individuals with pre- and post-measurement scores.


appropriate and adequate to answer the study question, and




Reviewer Comments:

KCBHO indicated it is using one key indicator to answer the question of whether the intervention will

reduce the number of ED visits for its chosen study population. It is an impartial, quantifiable way to

assess the impact of the implemented interventions.


data on the indicator are collected, all of the elements of the data


are in place in case sufficient data are not able to be collected.


Reviewer Comments:

KCBHO reported challenges obtaining data from all five of the MCOs; thus, the BHO considered

alternative means of accessing enrollee healthcare data as well as hospital ED data. As a result, King

County BHO has contracted with PreManage to provide client lists to match with hospital ED utilization

data. Using Medicaid eligibility files and the information obtained using EDIE/PreManage, the BHO is able

to access and analyze the data necessary for the study indicator.


unambiguously stated and appropriate in length. ● Fully Met (pass)

Reviewer Comments:

KCBHO has chosen December 1, 2015, through November 30, 2016, for its baseline measurement period


and September 2017, December 2017, and June 2018 (3, 6, and 12 months post intervention), for its re-

measurement periods.

Meets Criteria






confidence level, and the acceptable margin error are


●N/A

Reviewer Comments:




specified.

●N/A

Reviewer Comments:




Reviewer Comments:



Reviewer Comments:


N/A




6.1 The study design clearly specifies the data to be collected. ● Fully Met (pass)

Reviewer Comments:

The data elements that will be collected for this PIP include:

enrollment in Molina Healthcare’s Apple Health Plan

continuous enrollment in Molina and the BHO during the measurement periods

BHO and MCO enrollees age 18 or under as of November 30, 2016

ED visits for the PIP population during the baseline period of December 1, 2015, through

November 30, 2016, and the re-measurement periods of September 2017, December 2017, and

June 2018 (3, 6, and 12 months post intervention)

6.2 The study design clearly specifies the sources of data. ● Fully Met (pass)


Reviewer Comments:

The data sources for this PIP will include the administrative data from Medicaid eligibility files and

Emergency Department Information Exchange (EDIE)/PreManage.







Reviewer Comments:

Medicaid eligibility files are obtained by KCBHO from DBHR on a monthly basis. These files

display all Medicaid enrollees for the given month, BHO affiliation, and with which MCO the

individual is enrolled.

KCBHO is specifically looking at children and adolescents who are identified as being enrolled

with Molina.

Per KCBHO, the reliability/validity for this data is used by the State for Medicaid reconciliation and

penetration analyses and BHO payment, which is considered the “gold standard” for reliability.

EDIE/PreManage contains ED utilization data across the state of Washington. It identifies and

provides information on high-risk patients in real time. It is also a web-based communication tool

to assist with care coordination between different healthcare systems.

Per KCBHO, it is reliable and valid and used in several states.

Data collection processes:

1. From the monthly Medicaid eligibility files, the BHO extracts those individuals enrolled with Molina

during each of the 12 months of the baseline period.

2. From the BHO enrollment data, KCBHO then uploads a file containing this data to

EDIE/PreManage.

3. ED visits are identified and reported in EDIE/PreManage. A query is conducted to obtain ED

utilization reports.

4. KCBHO will utilize the report generated from EDIE/PreManage to analyze ED use at 3, 6, and 12

months post intervention.







Reviewer Comments:

The monthly Medicaid eligibility files include all Medicaid enrollees and the MCO with which the individual

is enrolled. Using these files as a basis, KCBHO queries the baseline for 12 months of files to extract

enrollees who are continuously enrolled in the BHO and Molina within all months of the baseline

measurement period. This extraction produces a file of individuals continuously enrolled in both systems

during the 12-month baseline period. A list of continuously enrolled youth is created by subtracting their

date of birth from November 30, 2016, to establish those who are 18 years old or younger. KCBHO’s

Performance Measurement Evaluator will generate a report from EDIE/PreManage to analyze ED use at

3, 6, and 12 months post intervention. Through the uses of STATA (a data analysis and statistical software

program), the evaluator may conduct further analysis.


qualifications to collect the data. ● Fully Met (pass)

Reviewer Comments:


KCBHO staff involved in collecting the data elements include a King County senior application developer

with King County IT, who has over a decade of programming experience. This individual extracts the data

from the monthly Medicaid eligibility files.

The subsequent analysis will be completed by KCBHO’s current performance measurement evaluator,

who holds a PhD in health services research and has over 15 years of research, program evaluation, and

quality improvement experience.


ensured. ●N/A

Reviewer Comments:

Not applicable; this PIP uses only administrative data.

Meets Criteria








Reviewer Comments:

KCBHO indicated it will use a paired two-tailed t-test to compare the average number of hospital ED visits

during the baseline period to the number during the re-measurement period. The total number of ED visits

for each individual during the baseline and re-measurement periods will be entered in STATA for

evaluation.


presented. ●N/A

Reviewer Comments:




Reviewer Comments:




correctly.

●N/A

Reviewer Comments:




Reviewer Comments:





●N/A


Reviewer Comments:



Valid data interpretation occurs when the analysis is carried out as planned. Results should be displayed

in an easily understood format. The analysis should include a comparison of the initial and repeat

measurements, and any threats to validity should be noted. KCBHO should include in the discussion

whether progress toward the PIP’s goal was made and details regarding any follow-up actions.





the PIP process. ●N/A

Reviewer Comments:

The PIP has not progressed to the point of identifying improvement strategies.



processes.

●N/A

Reviewer Comments:



processes or outcomes. ●N/A

Reviewer Comments:



appropriate. ●N/A

Reviewer Comments:



An improvement strategy is an intervention created to impact a cause/barrier in the PIP process. The

intent of the PIP is to implement real, sustained improvement through the ongoing use of a Plan, Do,

Study, Act (PDSA) problem-solving model. The interventions need to be sufficient to be expected to

improve processes or outcomes, and they must be culturally and linguistically appropriate.






Reviewer Comments:





Reviewer Comments:





not improvement.

●N/A

Reviewer Comments:





●N/A

Reviewer Comments:



Whether a change does or does not occur, KCBHO must assess components of the PIP to determine

whether the change or lack of change is attributable to an event unrelated to the intervention, random

chance, or to the intervention. Evaluation of results is the focus of this step.





measurements over comparable time periods. If improvement

was not sustained, there is an explanation and an indicated plan

for next steps.

●N/A

Reviewer Comments:

The PIP has not progressed to the point at which sustained improvement can be assessed.


This step, specifically, should not be addressed until KCBHO has completed its PIP. The ultimate goal of

the PIP is to achieve sustained improvement; however, if improvement is not sustained, an evaluation of

the PIP will be conducted and a plan for further action or retirement will need to be assessed by the BHO.


PIP Validation Results: Substance Use Disorder (SUD) PIP

SUD Residential Treatment Length of Stay

KCBHO identified a new SUD PIP topic in early 2017 and is still in the early stages of development and

implementation. The BHO intends to examine SUD residential lengths of stay from the initial authorization

through continued stay extension requests (re-authorizations). With the integration of mental health and

SUD treatment services in April 2016, KCBHO became responsible for the authorization and utilization

management of residential SUD treatment services. Because overseeing and authorizing SUD residential

treatment is a new business for the BHO and is a very costly service, KCBHO sought to assess lengths of

stay to determine if the BHO is authorizing SUD treatment for appropriate amounts of time. Enrollees who

are identified as needing residential treatment are among the most severely ill; thus, the BHO sees

importance in authoring appropriate lengths of stay at the onset to fully address the treatment needs of

these enrollees. KCBHO aims to provide the right treatment and the right amount of treatment at the right

time to those it serves.

Additionally, KCBHO seeks to minimize readmissions as well as reduce and/or prevent the number of

stay extensions. The BHO has not yet analyzed its SUD residential treatment data to determine where

the need exists.

Study question: “After implementation of an improved SUD residential treatment authorization process,

will we be able to reduce the number of stay extensions (reauthorizations) by X percent and rapid

readmissions (90-day readmission rate) by Y percent for adults (ages 18+) with Medicaid who are

seeking residential drug addiction treatment in King County?”

Dates of study period: January 2017 to October 2019

Table C-24: SUD PIP Validation Results

Study Design

Activity

SCORE


2 Clearly defined, answerable study question ● Partially Met (pass)

3 Correctly identified study population ●N/A

4 Correctly identified study indicator ●N/A


6 Accurate/complete data collection ●N/A


interpretation of study results ●N/A


Outcomes 8 Appropriate improvement strategies ●N/A



Overall Score

Confidence Level:

Not enough time has elapsed to assess meaningful

change


Reviewer Comments:

KCBHO is still in the early stages of this PIP and does not have the relevant data to determine whether

a problem truly exists with the current authorization process as it relates to SUD residential treatment

lengths of stay. Once the data are obtained, the BHO should consider homing in on a particular focus

area, such as discharge planning and post-discharge linkages for continuity of care. This will also aid

the BHO in developing its intervention.






care, and services.


Reviewer Comments:

The BHO is conducting a data analysis project to better understand how length of stay influences

treatment outcomes, and what other factors may influence lengths of stay, so the PIP is still in the

development process. KCBHO authorization staff and quality managers have shared initial feedback from

SUD residential treatment providers, who indicated the current initial care authorizations for SUD inpatient

treatment lengths of stay (15 days) may be too short.


of the enrollees. ● Fully Met (pass)

Reviewer Comments:

KCBHO preliminarily looked at data on Medicaid enrollees who obtained a substance use disorder

residential treatment authorization for the timeframe between July 1, 2016, and December 31, 2016.

During this time the BHO provided authorizations for 667 enrollees for 728 admissions to residential

treatment for substance use disorders. There were about 60 readmissions during this six-month time

period. Of the total authorizations, 64 percent were granted stay extensions, and, on average, there were

1.4 stay extensions per client for those who needed one, with a range of stay extensions from zero to five.

Those in the residential SUD treatment population represent about 14 percent of the Medicaid clients who

engaged in SUD treatment services in King County between July and December 2016.


was considered during the selection of the PIP. ●Not Met (fail)


Reviewer Comments:

In the selection of this study topic, the BHO did not involve stakeholders, including enrollees. KCBHO

indicated it intends to seek enrollee input as part of the process once it has established the methodology

for soliciting feedback from enrollees.


care and services. ● Partially Met (pass)

Reviewer Comments:

Enrollees who access SUD residential treatment have a high severity of drug use, and some are at high

risk for death due to overdose. KCBHO is seeking to understand how lengths of stay impact treatment

outcomes and what factors may affect optimal lengths of stay.

The BHO also identified the potential to “decrease administrative burden.” PIPs should not focus on

administrative fixes, but rather a process that will directly affect an enrollee’s experience with their SUD

treatment.


To determine the appropriateness of this study topic, the BHO should seek input from enrollees who have

received SUD residential treatment services. KCBHO has identified a plan to incorporate the input of

enrollees.




2.1 The study question(s) is clear, concise, and answerable. ● Partially Met (pass)

Reviewer Comments:

The study question is “After implementation of an improved SUD residential treatment authorization

process, will we be able to reduce the number of stay extensions (reauthorizations) by X percent and rapid

readmissions (90 day readmission rate) by Y percent for adults (ages 18+) with Medicaid who are seeking

residential drug addiction treatment in King County?”

In its current format, the study question is not answerable, as the BHO has not defined specific metrics for

X and Y. The BHO should narrow its focus so the study question is concise and easily answerable.


collection, analysis, and interpretation. ●Not Met (fail)

Reviewer Comments:

The study question is not stated in a way that supports the ability to determine whether the intervention

has a measurable impact for the defined population.





Reviewer Comments:

KCBHO needs to define the percentages for X and Y. The BHO should also define how extending the

original length of stay authorization impacts the readmission rate.



In order to have a clear, concise, and answerable study question that will set the framework for the PIP,

KCBHO must first clarify the exact issue it wishes to focus on improving and then determine what

intervention will be used to achieve the desired outcome. Currently, the scope of the study question is too

large, and there is not a clear correlation between the initial authorization and rapid readmissions.

Furthermore, without any data it is difficult to discern if this is an appropriate study question.

Standard 3: Study Population Is Clearly Defined, and, if a Sample Is Used, Appropriate

Methodology Is Used




are relevant is clearly defined. ●N/A

Reviewer Comments:

The PIP has not progressed to the point of defining its study population.

3.2 The inclusion or exclusion criterion, if applicable, is clearly

defined. ●N/A

Reviewer Comments:



population to which the study indicator applies, or a sample is

used.

●N/A

Reviewer Comments:



captured for all enrollees to whom the study question applied. ●N/A

Reviewer Comments:



KCBHO should clearly articulate the study population. The basis for any inclusions or exclusions should be

stated in a straightforward manner. The BHO needs to ensure that it has the capability to properly identify

individuals within the study population and that it can collect the required data.





clearly defined numerator and denominator. ●N/A

Reviewer Comments:

The PIP has not progressed to the point of defining a study indicator.


appropriate and adequate to answer the study question, and ●N/A




Reviewer Comments:



data on the indicator is collected, all of the elements of the data


are in place in case sufficient data is not able to be collected.

●N/A

Reviewer Comments:



unambiguously stated and appropriate in length. ●N/A

Reviewer Comments:



KCBHO needs to ensure that as it develops the study indicator, it includes a defined numerator and

denominator. The indicator should be objective, clear, and unambiguous, as well as actionable and

reliable. The BHO should include an explanation of how the indicators are appropriate and adequate to

answer the study question and describe how the indicator objectively measures change to impact the

enrollee.






confidence level and the acceptable margin error are


●N/A

Reviewer Comments:

The PIP has not progressed to the point of choosing a sampling method.



specified.

●N/A

Reviewer Comments:




Reviewer Comments:



Reviewer Comments:




If KCBHO uses a sampling technique, it must ensure that the sample is representative of the entire eligible

population. Sampling methods should be in line with generally accepted principles of research design and

statistical analysis.




6.1 The study design clearly specifies the data to be collected. ●N/A

Reviewer Comments:

The PIP has not progressed to the point of data collection.

6.2 The study design clearly specifies the sources of data. ●N/A

Reviewer Comments:







●N/A

Reviewer Comments:







●N/A

Reviewer Comments:



qualifications to collect the data. ●N/A

Reviewer Comments:



ensured. ●N/A

Reviewer Comments:



In order to have accurate and valid study results, data must be properly collected. The data analysis plan

should specify what data are to be collected; what the data sources are; how and when the data will be

collected; who will collect the data, including verification that they are qualified to collect the data; and

identification of any tools used to collect data. KCBHO should consider all the information needed in order

to identify the right study population, calculate the study indicator, analyze the results meaningfully, and

establish the validity and reliability of the data. The process should be simple, easy, and clear.








●N/A

Reviewer Comments:



presented. ●N/A

Reviewer Comments:




Reviewer Comments:




correctly.

●N/A

Reviewer Comments:




Reviewer Comments:





●N/A

Reviewer Comments:



An analysis plan should describe the schedule for data collection and analysis. KCBHO would benefit from

using a simple “task-by-timeline” format, as results should be displayed in an easily understood design.

The analysis should include a comparison of the initial and repeat measurements, and any threats to

validity should be noted. Interpretation involves looking at all the possible explanations for results and

factors that may have affected them, not just assuming that the intervention itself was the only operative

factor.






the PIP process. ●N/A

Reviewer Comments:




processes.

●N/A

Reviewer Comments:



processes or outcomes. ●N/A

Reviewer Comments:



appropriate. ●N/A

Reviewer Comments:



An improvement strategy is an intervention created to impact a cause/barrier in the PIP process. A barrier

analysis should be conducted to derive the improvement strategies to be implemented. KCBHO should

consider the following sources for potential interventions: stakeholder input, research studies, promising

practices, and data obtained from high-performing SUD treatment providers throughout Washington.






Reviewer Comments:




Reviewer Comments:





not improvement.

●N/A

Reviewer Comments:






●N/A

Reviewer Comments:



When a change in performance occurs, it must be determined whether the change is real, attributable to

an event unrelated to the intervention, or random chance. Whether a change does or does not occur,

KCBHO must assess components of the PIP to determine whether the change or lack of change is

attributable to the actual intervention. Evaluation of results is the focus of this step to determine if the

results are statistically significant.





measurements over comparable time periods. Sustained

improvement was demonstrated through repeated measurements

over comparable time periods. If improvement was not sustained,

there is an explanation and an indicated plan for next steps.

●N/A

Reviewer Comments:

The PIP has not progressed to the point at which sustained improvement can be assessed.


This step should not be addressed until KCBHO has completed its PIP. If real change has occurred, the

PIP should be able to achieve sustained improvement. Sustained improvement is demonstrated through

repeated measurements over time.

81 Information Systems Capabilities Assessment

Information Systems Capabilities Assessment (ISCA)

Qualis Health’s subsidiary, Outlook Associates, examined King County Behavioral Health Organization’s

information systems and data processing and reporting procedures to determine the extent to which they

support the production of valid and reliable State performance measures and the capacity to manage

care of BHO enrollees.

ISCA Methodology

The ISCA procedures were based on the CMS protocol for this activity, as adapted for the BHOs with

DBHR's approval. For each ISCA review area, Outlook Associates used the information collected in the

ISCA data collection tool, responses to interview questions, and results of the claims/encounter and

security walkthroughs to rate the BHO's performance for seven review areas. Scores are based on fully

meeting, partially meeting, or not meeting standards. Although not rated, the BHO's meaningful use of

EHR systems was also evaluated.

The ISCA review process consists of four phases:

Phase 1: Standard information about the BHO’s information systems is collected. The BHO

and two of its delegated provider agencies complete the ISCA data collection tool before the on-

site review.

Phase 2: The completed ISCA data collection tools and accompanying documents are

reviewed. Submitted ISCA tools are thoroughly reviewed. Wherever an answer seems

incomplete or indicates an inadequate process, it is marked for follow-up. If the desktop review

indicates that further accompanying documents are needed, those documents are requested.

Phase 3: On-site visits and walkthroughs with the BHO and two delegated provider

agencies are conducted. Claims/encounter walkthroughs and data center security walkthroughs

are conducted. In-depth interviews with knowledgeable BHO staff and delegated provider agency

staff are conducted. Additional documents are requested, if needed, based upon interviews and

walkthroughs completed at the BHO and at two delegated provider agencies.

Phase 4: Analysis of the findings from the BHO’s information system on-site review

commences. In this phase, the material and findings from the first three phases are reviewed in

cooperation with the BHO and selected delegate provider agencies to close out any open review

questions. The BHO-specific ISCA evaluation report is then finalized.

Each of the items in the review areas were evaluated against industry standards for health data

information systems, especially Medicaid Management Information Systems. Table D-1 describes those

standards.


Table D-1: ISCA Scoring Standards

Citation Issuing Body Description of Standard

45 CFR 160 Health & Human Services (HHS) Federal regulations for general administrative requirements pertaining to security and privacy.

45 CFR Part 164 Health & Human Services (HHS) HHS Standards for Security and Privacy Part 164 covers security and privacy of individually identifiable health information.

ISO/IEEE 29119 International Standards Organization/Institute of Electrical and Electronics Engineers

Contains five standards that define an internationally agreed upon set of standards to support software testing.

NIST

National Institute of Standards and Technology

NIST Special Publications 800 series provides a catalog of security controls for all U.S. federal information systems except those related to national security. NIST standards have been incorporated into CMS security controls such as the Minimum Acceptable Risk Standards catalog of security and privacy controls.

ANSI ASC X 12 American National Standards Institute, the Accredited Standards Committee

Uniform standards for inter-industry electronic exchange of business transactions, namely electronic data interchange.

ISO/IEC 27000:2016, 27001:2013, and 27002:2013

International Organization for Standardization/International Electrotechnical Commission

Series of international standards providing best practice recommendations on information security management.

42 CFR Part 438 Health & Human Services (HHS), Centers for Medicare & Medicaid Services

Federal regulations for Medical Assistance Programs, Managed Care. Subpart F pertains to Grievance and Appeals Systems.

The table below presents the scoring key for the ISCA standards.

Scoring Icon Key


Summary of Results

KCBHO passed the majority of the ISCA, which revealed only several minor issues. KCBHO’s systems

and associated processes are well established and managed. The King County Information Technology

(KCIT) department operates its own data center, with all servers located off site in the county facility

hosted by the Sabey Corporation Seattle data facility. The BHO is able to utilize resources from KCIT to

https://en.wikipedia.org/wiki/Information_systems


assist with programming, infrastructure support, and security issues and is meeting all contractual

obligations for information systems management.

During the on-site interviews, the review team focused on data integrity and data security. KCBHO

described the process of obtaining data from the BHAs and the measures it takes to ensure that all data

are submitted to the BHO in a timely manner. A portion of the on-site interview included a walkthrough of

the BHO’s office to validate that best practice security measures were being followed.

Two minor issues of access control non-compliance were found during the review. The NIST security

standard is that user accounts are automatically disabled after 60 days of inactivity; however, KCBHO

procedure is removal after a year of inactivity. KCBHO also allows five failed login attempts before locking

the user out; the standard is three.

There were also two areas of concern related to disaster recovery and continuity of operations:

continuous monitoring or periodic review of plans and procedures

periodic testing of those plans

The KCIT Emergency Management Response Plan (EMRP) and Continuity of Operations Plan (COOP)

do not include any reference to review since the last update in 2013. The KCIT Continuity of Operations

Plan indicates that formatting changes were made to the document in January 2017 but does not specify

whether the document had been reviewed since approval in 2013.

The KCIT Business Continuity Plan describes the KCIT Enterprise Business Continuity Program

objectives, risks, benefits, key performance indicators, five-phase approach, and phase progress. The

program emphasizes the need for regular testing and updating of the Business Continuity Plan. But

whereas phases 1 and 2 appear complete as of July 2015, no dates of completion are indicated for

Phase 4—Design the Testing for Business Continuity Plan and Phase 5—Implement Testing.

The EMRP specifics for testing (technical and business) steps, from initial assessment through recovery

and return to facility, are well defined. The COOP also references a continuity testing, training, and

exercise (TT&E) program as a continuity objective; however, no details were present. CMS Security and

Privacy Controls (MARS-E CP-4) require annual testing of a contingency plan. Although industry

standards allow the organization to define the frequency of contingency testing (NIST SP 800-53r4),

these documents indicated nothing with regard to frequency.

The other issues highlighted in this review relate to weakness identified at the two provider agencies the

review team visited. The following sections identify opportunities for the BHO to increase monitoring,

technical assistance, and education of its providers in the areas of security and data quality.

In April 2016, KCBHO began accepting service data from its contracted substance use disorder (SUD)

treatment providers. The BHO acknowledged that while the initial process had been tedious, all providers

are now submitting data. The BHO provided training and systems support during the transition. KCBHO

also provides a web-based application developed in house for batch creation.

KCBHO monitors encounter data and provided analyses of completeness and timeliness of the data.

During site reviews, KCBHO contract monitors validate annual encounter data against chart reviews.


Table D-2: ISCA Scores by Section

ISCA Section

Description ISCA Result

Overall ISCA Score This is the overall score for the BHO's ISCA. ● Partially Met (pass)

A. Information Systems

This section assesses the BHO’s management of the information systems.


B. IT Infrastructure This section assesses the BHO’s network infrastructure.


C. Information Security

This section assesses the security of the BHO’s information systems.


D. Encounter Data Management



E. Eligibility Data Management



F. Provider Data Management

This section assesses the BHO’s ability to maintain accurate provider information.


G. Performance Measures and Reporting



H. Meaningful Use of Electronic Health Records (EHRs)

This section is used to assess how the BHO and its providers use EHRs. This section is not scored.

● N/A

ISCA Section Details

KCBHO’s detailed ISCA review findings are presented in the following sections. Each ISCA subsection

features a score corresponding to the “Met,” “Partially Met,” and “Not Met” scoring system. For each

subsection, if a recommendation requiring a corrective action plan (CAP) has been issued, the subsection

will receive a score of Not Met or Partially Met, depending on the severity, and the section will also

receive that corresponding score. If a subsection receives recommendations for an opportunity for

improvement, the subsection will receive a score of Partially Met or Fully Met, and the section will also

receive that corresponding score, unless another subsection received a score of Not Met. If no

recommendations are noted within a subsection, the subsection receives a score of Fully Met. If all

subsections receive a score of Fully Met, the section also receives a score of Fully Met.

Score Description

●Not Met (fail) Recommendation Requiring CAP(s) issued

●Partially Met (pass) Recommendation for Opportunity for Improvement(s) issued

●Fully Met (pass) No Recommendations issued


ISCA Section A: Information Systems

This section assesses the BHO’s management of the information systems, specifically examining the

BHO’s capacity for collecting, storing, analyzing, and reporting client treatment data.

Characteristics of well-managed systems include:

data structure that supports complex queries that can be changed easily

secure access via authentication with permission levels

written policies and procedures that support industry standard and best practice IT management

reasonable system response times

complete and consistent testing procedures

clear version control procedures

ability to make changes to systems with minimal disruption to users

adequate training and user documentation

open communication with end users of information system changes and issues

KCBHO demonstrates the majority of these characteristics.

KCBHO has developed databases and applications in house, using the KCIT data center servers and

server applications as its primary management tools, for collecting data from its providers and for meeting

reporting requirements with the State. The KCIT data center is hosted at the Sabey Corporation Seattle

facility and provides secure network and remote access for KCBHO and its providers. KCIT utilizes the

IBM Informix Dynamic Server for its relational database, Hewlett-Packard DL380p Gen8 servers for its

database and application servers, Appeon PowerBuilder for client-server applications, SQL Server

Reporting Services for online reports, Informix 4GL for batch processing, Cisco AnyConnect VPN for

remote access, and Windows Server 2008R2 for its remote desktop server. KCBHO requires its

contractors to transmit their data files either by using secure FTP or by direct input, using the KCBHO-

supplied direct data entry application. However, many of the providers use other commercial software for

their internal electronic medical records (EMRs).

KCIT participates in DBHR’s Behavioral Health Data Group meetings to identify updates requiring

KCBHO system changes necessary to meet the State's needs. Changes are documented in the data

dictionary section of the KCBHO Policies and Procedures manual. Provider management and technical

staff are notified verbally and in writing of the modifications.

KCBHO uses industry standard procedures when upgrading or modifying its system. KCIT and KCBHO

restrict access to the data through a role-based mechanism.

Strengths

KCIT has sound IS management policies in place consistent with current technologies.

KCIT’s Business Continuity Program leverages the data center, dedicated infrastructure, hosted

services (AWS), and virtualization to minimize risk to information systems and business

operations.

All KCIT programming work is performed in house. Its programmers, averaging ten years of

experience and seven years of tenure, have experienced no turnover in the past three years.

KCIT budgets for programmers to receive approximately five days of training per year to enhance

their technical skills.


Testing processes comply with industry standards. System changes and updates use formal best

practices protocols.

KCBHO holds regular meetings with its providers to discuss IT issues.

KCBHO performs reconciliations with the State for capitation payments, in-patient payments, and

data in ProviderOne.

Weaknesses

Written IT policies and procedures do not indicate the last date of review.

Providers require additional notice when changes to the data dictionary or file format occur.

Table D-3: Results for Section A: Information Systems

Sub-Area Issues Recommendation Score Standard

IS Management Policies

Annual review lacks indication of most recent review date

Include review section in documents or develop central document tracking policy for review dates

●

45 CFR §§160 and 164; BHO Contract Section 10.10.1

Reconciliation and Balancing

None None ● BHO Contract

Training None None ● 45 CFR §164.312

Testing Procedures

None None ● ISO/IEEE 29119

System Changes and Version Control

None

Allow a longer lead time on changes to the system so that providers have time to make changes to their systems

● NIST SP 800-28

EDI None None ●

45 CFR §164.312; ANSI ASC X12

Total Score ●

Opportunities for Improvement

Written IT policies and procedures do not indicate the last date of review.

KCBHO should make the currency of policies and procedural documentation available. One

option is to add a review section to include the creation or modification date and a brief

description of the change. Another option is to maintain a tracking sheet of all policies to include

the last review date and indication of whether the policy was modified.

Providers need at least a 90-day lead time to make changes to their EHR systems to allow for executing

the changes, communicating those changes to staff, and adequately testing those changes.

When changes to provider EHR systems are needed immediately, the BHO should work with the

providers to allow a grace period for filing edits and correcting errors.


ISCA Section B: IT Infrastructure

This section assesses the BHO’s network infrastructure and the BHO’s ability to maintain its equipment

and telecommunications capacity to support end users’ needs.

Characteristics of a well-managed IT environment include:

adequate maintenance staff or maintenance contracts to ensure timely replacement of computer

equipment and/or software

adequate staff or contracts that ensure timely responses to emergent and critical system failures

redundancy within the data center hardware that minimizes the length of system outages, loss of

data, and disruption of end user service.

business continuity and disaster recovery (BC/DR) plans that are maintained and tested regularly.

KCBHO demonstrates all of these characteristics.

KCBHO’s infrastructure meets the needs of both the internal and external users. Its network servers are

configured to provide required redundancy. The system is available to the providers 24/7, and outages

are rare.

Strengths

KCIT adheres to industry standard backup procedures and data redundancy techniques.

System backups are performed every three hours to the cloud and tested monthly.

KCBHO uses secure role-based access for printing and faxing. Security administration

techniques conform to industry standards and best practices. All servers are located in a secure,

off-site facility monitored 24/7 with optimal physical security safeguards and redundancy for

HVAC, network connections, and power.

KCIT’s Sabey data facility provides excellent infrastructure security: power, cooling, network

connectivity, and 24/7 control and monitoring.

Systems are available 24/7. In addition, contracts exist with the vendor responsible for

equipment maintenance for four-hour response time on critical issues.

Backups are tested monthly by restoring the database and running business applications against

it.

Weaknesses

The business continuity and disaster recovery plans do not provide the frequency for periodic

testing. As mentioned in the Information Systems section, there is no record of when the plans

were last reviewed and updated.

Table D-4: Results for Section B: IT Infrastructure


Redundancy None None ●

45 CFR §164.308; NIST SP 800-34

Data Center/ Server Room

None None ● 45 CFR §164.308



Back Up BC/DR plans lack testing information

Update the BC and DR plans to include testing parameters ●

45 CFR §164.308; NIST SP 800-34; BHO Contract

Network Availability

None None ●

ISO Network Management Model (FCAPS)

Total Score ●


KCBHO’s business continuity and disaster recovery plans do not indicate frequency of periodic testing.

KCBHO needs to periodically test its BC/DR plans. The plans should indicate the frequency of

testing and the type of testing performed.


ISCA Section C: Information Security

This section assesses the security of the BHO’s information systems and the safeguards in place to

proactively avoid malicious access to facilities and/or data systems, intrusions, and breaches of protected

health information (PHI) and personally identifiable information (PII).

Characteristics of good security management include:

physical security safeguards at all facilities

policies and procedures that adhere to national healthcare security standards, include specific

references and guidelines for mobile devices, and are routinely reviewed and updated

procedure to remove access to appropriate systems when an employee or contractor leaves,

which includes an expedited path in case of emergency

dedicated security administration staff, adequate to support the agency and its internal and

external users

policies and procedures that adhere to HIPAA Security and Privacy standards, including the

reporting and remediation of security and privacy breaches

KCBHO demonstrates these characteristics, with the exception noted below.

KCBHO takes security seriously and demonstrates understanding and adherence with national security

standards.

Strengths

KCBHO and its agencies have strong security policies in place. The policies cover current

technology, such as portable devices including smart phones and tablets.

The BHO has policies and procedures in place to quickly remove access to the system.

The KCIT Data Center provides a monthly report on penetration and vulnerabilities to all security

managers. Vulnerability tests are routinely performed, and risks must be mitigated or documented

for risk acceptance.

Random checks for privacy screen usage are conducted by the KCBHO compliance officer.

Weaknesses

The BHO policy for disabling inactive accounts is to disable after one year of inactivity, whereas

the NIST standard is for 60 days.

The BHO allows five invalid login attempts into its system before lock-out; the industry standard is

three.

During the on-site review of a KCBHO provider agency, the provider noted that it does not require

visitor login and badging. Best practice security measures are that any non-staff person should

sign a visitors log and be issued a visitor badge.

Table D-5: Results for Section C: Information Security


Physical Security

None None ●

45 CFR §164.310; NIST SP 800-66; BHO Contract Section 3.4.4



Security Policies

None None ●

45 CFR §§164.308,164.312; NIST SP 800-39; BHO Contract Section 3.4.4

Security Testing None None ● NIST SP 800-53, 115

Access Removal Policies

Inactive accounts are not disabled according to industry standards

Implement automatic disabling of accounts inactive after 60 days

●

45 CFR §§164.308,164.312; ISO/IEC 27000:2016–27002; BHO Contract Section 3.4.4

Mobile Device Security and Policies

None None ● 45 CFR §§64.308,164.312; NIST SP 800-124

Total Score ●


During the on-site review of a KCBHO provider agency, the provider noted that it does not require visitor

login and badging.

The BHO should notify its agencies that best practice security measures are that any non-staff

person sign a visitors log and be issued a visitor badge.

The BHO allows five invalid login attempts into its system before lock-out.

KCBHO should reduce the number of invalid login attempts into its system before lock-out from

five to three, per industry standard.


The BHO policy for disabling inactive accounts is to disable an account after one year of inactivity; the

NIST standard is for 60 days.

KCBHO needs to modify its policy to disable inactive accounts after 60 days.


ISCA Section D: Encounter Data Management


Characteristics of good encounter data management include:

documented procedures on encounter data submission, which include timeframes and validation

check

automated edit and validity checks of key fields

production of error reports and procedures to correct those errors

periodic audits to validate the encounter data

regular meetings with agency staff to ensure all data are captured accurately and in a timely

manner

reconciliation procedures that compare BHO data to provider data


KCBHO works with its providers to capture complete and accurate encounter data. The BHO has

established policies that include deadlines for data submission. KCBHO performs annual encounter data

validation of its providers’ data. The BHO provides a number of reports and tools to assist providers in

managing their service data. KCBHO’s IT environment is conducive to timely and complete data entry.

Service data are not accepted unless there is a valid authorization for the majority of the services

delivered by the providers.

Strengths

KCBHO has smart data management policies in place that require data to be edited at the

source. The BHO will return any incorrect data to the originator for modification.

KCBHO follows best practice standards by returning an acknowledgement file to the agencies

with the count of files received.

KCBHO conducts annual data validation of its provider agencies.

KCBHO has a procedure in place for reconciling data with the State to further ensure that

encounter data are complete.

KCBHO created an application for SUD residential treatment services that tracks movement out

of residential facilities and auto-generates the encounter for submission.

Weaknesses

KCBHO does not perform a random validation of services with members in order to detect fraud.

Provider agencies are struggling to correct their encounter data and resubmit in a timely manner.

Table D-6: Results for Section D: Encounter Data Management


Data Validation None None ●

42 CFR §438.242; 45 CFR §164.312

Error Handling BHAs are not consistently

Provide additional education to providers on error correction of ●

45 CFR §164.312


Sub-Area Issues Recommendation Score Standard reconciling encounter data and correcting errors in a timely manner

encounters

Auditing Random validation is not performed

Perform random validation of services with members ●

42 CFR §438.608; 45 CFR §164.312

Total Score ●


KCBHO does not perform a random validation of services with members in order to detect fraud.

KCBHO should perform a random validation of services with members by sending notices of

services to randomly selected members documented as having received those services and

asking members to review and acknowledge that they received those services.

Provider agencies are struggling to correct their encounter data and resubmit them in a timely manner.

The BHO should use its monthly IT meetings with providers to educate them about proper data

reconciliation and correction techniques.


ISCA Section E: Eligibility Data Management


Characteristics of good management of eligibility data include:

uploading of monthly eligibility data from the State with reconciliation processes in place

uploading and applying eligibility data changes from the State in between monthly files

managing internal eligibility files to eliminate duplicate member records

running reports to identify changes in eligibility that effect service data

KCBHO demonstrates most of these characteristics.

The BHO and all of its agencies use ProviderOne as the authority on eligibility data. KCBHO stated that it

is unable to apply the daily eligibility file changes from the State; however, it does send requests to

ProviderOne daily and receives the electronic transaction in return. That transaction is applied to the

KCBHO database. The monthly eligibility file is processed and checked for retroactive eligibility that may

impact encounters. The BHO deletes encounters that have been submitted during periods when eligibility

has been lost and submits encounters that were previously not eligible for submission upon learning of

retroactive eligibility. The BHO delegates eligibility management to its providers and requires them to do

regular and frequent checks of eligibility for their clients.

Strengths

The BHO has policies that require all providers to perform eligibility checks at the time of intake

and service delivery, as well as monthly, against ProviderOne. Some perform manual checks and

others submit eligibility requests electronically in batch mode.

BHAs do not immediately drop individuals when Medicaid coverage is lost. The agencies work

with the individuals to reinstate coverage or locate an alternate source to temporarily fund their

medically necessary services. Clinicians are notified of impending loss of eligibility and work with

the client to restore eligibility.

Reports are generated to identify duplicate clients who have been entered in error; these cases

are corrected manually. The providers work with the BHO to correct the records without losing

service history.

KCBHO manages retroactive eligibility and performs nightly checks against encounters to identify

those that can be sent to the State and those that need to be withdrawn.

Weaknesses

Maintaining up-to-date information in the eligibility data in ProviderOne can involve a considerable

amount of effort. Applying and managing the additions and removals that occur during the month

may require the BHO to contact the Health Care Authority (HCA) and DBHR to make manual

corrections.

Table D-7: Results for Section E: Eligibility Data Management

Sub-Area Issues Recommendation Score Standard Eligibility Updates and Verification

None None ●

42 CFR §§438.242, 438.608;


Sub-Area Issues Recommendation Score Standard Process BHO

Contract

Duplicate Management

None None ●

42 CFR §§438.242, 438.608

Eligibility Loss Management

None None ●

42 CFR §§438.242, 438.608

Total Score ●

Meets Criteria


ISCA Section F: Provider Data Management

This section assesses the BHO’s ability to maintain accurate and timely provider information.

Characteristics of good provider data management practices include:

establishing a communication process to update and maintain provider credentials, licenses, and

skill sets

supporting information systems that integrate provider information with member and service data

developing and maintaining policies and procedures that support timely exchange of provider

information

using provider data to edit encounter data to ensure that qualified providers are performing

services they are qualified to perform

KCBHO demonstrates these characteristics.

KCBHO integrates provider data into its database and uses it during encounter processing.

Strengths

The BHO has good processes for tracking credentialing and provider characteristics for the

provider directories and internal referrals.

Weaknesses

Occasionally, encounters are rejected because of provider data issues. Providers are required to

notify the BHO when license renewals or other changes to provider data occur, but they may not

always do so in a timely manner.

Table D-8: Results for Section F: Provider Data Management


Provider Directory Management

None None ●

42 CFR §§438.242, 438.608; BHO Contract

Payment Reconciliation

None None ●

42 CFR §§438.242, 438.608

Total Score ●

Meets Criteria


ISCA Section G: Performance Measures and Reporting


Characteristics of good reporting practices include:

use of encounter data, member data, and service data from an integrated database as the

primary source for performance measurements

policies and procedures that describe how the organization maintains data quality and integrity

staff dedicated and trained in all tools to develop queries and tools for reporting

support for continuing education of staff responsible for reporting metrics

use of data for program and finance decision making

use of analytics software and other industry standard reporting tools


KCBHO has worked diligently to use Avatar data in performance and management reporting. BHO staff

are gaining more experience with using data as a tool and thinking of creative ways to identify areas for

improvement. The BHO is using standard reporting and analytics tools in addition to utilizing reporting

mechanisms within Avatar.

Strengths

KCBHO has established regional and state performance measures, compiled from decision

support tables in its primary information system.

Table D-8: Results for Section G: Performance Measures and Reporting


Performance Measure Processes

None None ●

42 CFR §438.242; BHO Contract

Validation of Performance Metrics

None None ● BHO Contract

Documentation of Metrics

None None ● N/A

Appeals and Grievances None None ●

BHO Contract Section 7

Total Score ●

Meets Criteria


ISCA Section H: Meaningful Use of Electronic Health Records (EHRs)

This section of the ISCA is not scored. All KCBHO providers are using EHRs.

99 Encounter Data Validation

Encounter Data Validation (EDV) Encounter data validation (EDV) is a process used to validate encounter data submitted by Behavioral

Health Organizations (BHOs) to the State. Encounter data are electronic records of the services provided

to Medicaid enrollees by behavioral health agencies (BHAs) under contract with a BHO. Encounter data

are used by BHOs and the State to assess and improve the quality of care and to monitor program

integrity. Additionally, the State uses encounter data to determine capitation rates paid to the BHOs.

Prior to performing the data validation for encounters, Qualis Health reviewed the State’s standards for

collecting, processing, and submitting encounter data to develop an understanding of State encounter

data processes and standards. Documentation reviewed included:

the Service Encounter Reporting Instructions (SERI) in effect for the date range of encounters

reviewed

the Behavioral Health Data System for BHOs

the Health Care Authority Encounter Data Reporting Guide for Managed Care Organizations,

Qualified Health Home Lead Entities, and Behavioral Health Organizations

the 837 Encounter Data Companion Guide ANSI ASC X12N (Version 5010) Professional and

Institutional, State of Washington

Qualis Health performed three activities supporting a complete encounter data validation for KCBHO: a

review of the procedures and results of the BHO’s internal EDV required under the BHO’s contract with

the State; State-level validation of all encounter data received by the State from the BHO during the

review period; and an independent validation of State encounter data matched against provider-level

clinical record documentation to confirm the findings of the BHO’s internal EDV.

Validating BHO EDV Procedures Qualis Health performed independent validation of the procedures used by the BHO to perform encounter

data validation. The EDV requirements included in the BHO’s contract with DBHR were the standards for

validation.

Qualis Health obtained and reviewed the BHO’s encounter data validation report submitted to DBHR as a

contract deliverable for calendar year 2016. The BHO’s encounter data validation methodology,

encounter and enrollee sample size(s), selected encounter dates, and fields selected for validation were

reviewed for conformance with DBHR contract requirements. The BHO’s encounter and/or enrollee

sampling procedures were reviewed for conformance with accepted statistical methods for random

selection.

The BHO submitted a copy of the tool (spreadsheet, database, or other application) used to conduct

encounter data validation, along with any supporting documentation, policies, procedures, or user guides,

to Qualis Health for review. Qualis Health’s analytics staff then evaluated the tool to determine whether its

functionality was adequate for the intended program.


Additionally, the BHO submitted documentation describing its data analysis methods, from which

summary statistics of the encounter data validation results were drawn. The data analysis methods were

then reviewed by Qualis Health analytics staff to determine validity.

Qualis Health Encounter Data Validation

Qualis Health’s encounter data validation process consists of electronic data checks—State-level

validation of all encounter data received by the State from the BHO during the review period—and a

clinical record review—independent validation of State encounter data matched against provider-level

clinical record documentation to confirm the findings of the BHO’s internal EDV.

Electronic Data Checks

Qualis Health analyzed encounter data submitted by the BHO to the State to determine the general

magnitude of missing encounter data, types of potentially missing encounter data, overall data quality

issues, and any issues with the BHO’s processes for compiling encounter data and submitting the data

files to the State. Specific tasks included:

a review of standard edit checks performed by the State on encounter data received by the BHO

and how Washington’s Medicaid Management Information System (MMIS) treats data that fail an

edit check

a basic integrity check on the encounter data files to determine whether expected data exist,

whether the encounter data element values fit within expectations, and whether the data are of

sufficient quality to proceed with more complex analysis

application of consistency checks, including verification that critical fields contain values in the

correct format and that the values are consistent across fields

inspection of data fields for general validity

analysis and interpretation of data for submitted fields, the volume and consistency of encounter

data and utilization rates, in aggregate and by time dimensions, including service date and

encounter processing data, provider type, service type, and diagnostic codes

On-site Clinical Record Review

Qualis Health performed clinical record reviews on site at provider agencies under contract with the BHO.

The process included the following:

selecting a statistically valid sample of encounters from the file provided by the State

loading data from the encounter sample into an auditing tool (MS Access database) to record the

scores for each encounter data field

providing the BHO with a list of the enrollees whose clinical charts were selected for review for

coordination with contracted provider agencies pursuant to the on-site review

Qualis Health staff reviewed encounter documentation included in the clinical record to validate data

submitted to the State and to confirm the findings of the analysis of State-level data.


Upon completion of the clinical record reviews, Qualis Health calculated error rates for each encounter

field. The error rates were then compared to error rates reported by the BHO to DBHR for encounters for

which dates of service fell within the same time period.

Sampling Methodology

With the integration of mental health and substance use disorder (SUD) treatment services, Qualis Health

revised the sampling methodology in order to ensure an appropriate representation of encounters in the

sampled data.

For each BHO, Qualis Health received two data files from the State: one with patient demographics and

another with encounter-level data. Qualis Health first processed the raw data, then validated that all data

contained sufficient information to be included in a sample (most encounters, for example, should contain

a first name, last name, and birthdate). Qualis Health then verified that the data were appropriate to the

agency size and type. For example:

The volume of encounter data should be in an amount proportional to agency size; i.e., large

agencies should have a larger number of encounters than smaller agencies.

Procedure codes and modifiers should be consistent with an agency’s primary business function;

i.e., methadone clinics should submit encounters for services expected to be provided at a

methadone clinic.

All expected services should be reflected in the data; i.e., if withdrawal services are typically

provided at a particular type of agency, procedure codes reflecting those services should appear

in the overall dataset.

Once Qualis Health verified the completeness of the data, the required number of agencies were

selected, including two mental health agencies and four SUD treatment agencies.

Using the SERI, the procedure codes and modifiers were mapped to seven service modalities:

1. Mental Health

2. Substance Use: Assessment Services

3. Substance Use: Outpatient Case Management

4. Substance Use: Opiate Substitution

5. Substance Use: Outpatient Treatment

6. Substance Use: Residential Services

7. Substance Use: Withdrawal Management

The mental health and substance use encounters were separated; then, using J.R. Chromy's method of

sequential random sampling, one sample was pulled for each group, with roughly 35 to 50 patients per

unique BHA/agency pair (RUID) combination. Once the sample patients were selected, the patients and

the service modalities were merged with the encounter data. Upon this merge, reviewers verified that the

samples contained the required number of encounters (at least 411 encounters for mental health and at

least 411 for SUD, for more than 822 encounters in total for the BHO) and that all service modalities for

SUD treatment services in a given BHO’s data were represented.

The substance use sample must contain encounters from each of the six substance use modalities listed

above in proportion to overall volume of these modalities in each of the selected BHO/agency

combinations. For example, if an agency only performs services in the withdrawal management modality,

the sample will only contain sample patients from that agency who have received services in this


modality. Likewise, for agencies providing services representing all six substance use modalities, the

sample will contain encounters for services the agency has provided from all six modalities.

Scoring Criteria

Scoring Icon Key


KCBHO EDV Procedures

Qualis Health reviewed the sampling procedure and overall sample size to evaluate KCBHO’s adherence

to the contractually required sampling methodology.

Table E-1: Results for Review of BHO EDV Procedures


Sampling Procedure

Sampling was conducted using an appropriate random selection process and was of adequate size.

●Partially Met (pass) ●Partially Met (pass)

Review Tools Review and analysis tools are appropriate for the task and were used correctly.

●Fully Met (pass) ●Fully Met (pass) Methodology and Analytic Procedures

The analytical and scoring methodologies are sound, and all encounter data elements requiring review were examined.


Sampling Procedure

KCBHO sampled from Medicaid-funded and non-Medicaid-funded encounters that occurred from April 1,

2016, through October 31, 2016, for 29 behavioral health agencies that provide both SUD treatment and

mental health services. An overall sample size of 1,693 (1,071 Medicaid-funded) encounters was

selected. KCBHO reviewed only Medicaid-funded encounters for 17 agencies.

The data source for the sample was the King County Behavioral Health and Recovery Division

Information System (BHRD-IS). This source contains demographics, authorizations, and service

encounters submitted by the BHAs for all clients enrolled in KCBHO services.

KCBHO used proportional random sampling based on agency size and client type (adult or child).

KCBHO selected the charts randomly, without regard to recipient mix. The same number of encounters

(up to five) was usually selected from each chart, unless a chart contained fewer encounters. The

resulting sample mix was representative of the age composition of the Medicaid population KCBHO

serves.


Strength

KCBHO stratified its samples by agency size and client type and pulled clients proportionally

based on the number of clients at each agency. This approach appears to have provided an

unbiased and representative sample.


Ideally, a sequence of encounters would be selected for each client to ensure that all encounters in the

BHO (or State) database are present in the chart and that there are no duplicates.

To improve the efficiency of the EDV process, the BHO should select a smaller number of clients

and a larger set of encounters for each client, allowing reviewers to retrieve fewer client charts

during the on-site reviews.

KCBHO presented overall results of its EDV, rather than separating results for SUD and mental health.

In order to better identify trends, KCBHO should clearly state which agencies provide SUD

treatment or mental health services or both. Additionally, encounter samples should be broken

out by type of service for both SUD and mental health.


KCBHO did not clearly document the number of client charts selected for its sample in its DBHR

deliverable, so it was not possible to determine whether the BHO met its contract-required minimum of

selected encounters.

KCBHO should clearly state the number of client charts selected for its sample within its

deliverable to DBHR.

Review Tools

KCBHO did not submit a copy of its tool to Qualis Health for review; however, the BHO provided a

description of the spreadsheet within its State deliverable with numerous screenshots. KCBHO developed

and utilized an Excel tool using macros and queries. A programmed Excel rating sheet for each agency

listed each client and the service encounters to be reviewed. The raters entered results from their review

directly onto the rater sheet. Findings were then rolled up into a master document. Data validation checks

within the Excel tool and data quality checking macros in the master sheet prevented errors.

In its review tool, KCBHO included the following data elements:

date of service

name of service provider

service location

procedure code

service unit/duration

provider type

KCBHO’s spreadsheet did not contain the field “service code agrees with treatment described,” a DBHR

contract-required element.


KCBHO did not submit a copy of its review tool in its State deliverable, which is a contract requirement

and would facilitate a more effective review of the tool.

KCBHO needs to submit a copy of its review tool in its DBHR deliverable.


In a repeat finding from the 2016 EQR, KCBHO’s review tool did not include fields for all of the DBHR-

required elements; specifically, “service code agrees with treatment described” was not present in the

Excel spreadsheet tool.

KCBHO needs to include all contract-required elements in its review tool.

Methodology and Analytic Procedures

KCBHO notified each agency one month prior to its site visit of the date(s) of the upcoming record review,

and sent the list of clinical charts to be reviewed three business days prior to the day of the on-site visit.

The EDV review team consisted of six bachelors- and masters-level contract monitors who received

annual training prior to the on-site reviews. The review team participated in the development of review

tools. Reviews were conducted on-site at the agencies.

KCBHO reported an overall match rate of 65 percent, which is below the 95 percent contract requirement.

The “no match” rate was 35 percent, of which 30 percent was erroneous, 3 percent was missing, and 1

percent was unsubstantiated. Of the 17 (out of 29) mental health agencies reviewed, none met or

exceeded the 95 percent match rate. KCBHO reported the aggregate results for each agency, but did not

report the error rate for each data element. The BHO’s contract with DBHR requires analysis and

reporting of error rates for each data element, as well as aggregation of the results.


KCBHO reported only aggregate results for each agency, whereas the BHO-DBHR contract requires

analysis and reporting of the error rate for each data element. This was a repeat finding from the 2016

EQR.

KCBHO needs to provide the error rates for all data elements in its State deliverable.

Qualis Health Encounter Data Validation

Results below reflect each of the EDV activities performed, including electronic data checks of

demographic and encounter data provided by DBHR, on-site reviews comparing electronic data to data

included in the clinical record, and a comparison of Qualis Health’s EDV findings to the internal findings

reported by the BHO to DBHR for the same encounter date range.

Table E-2: Qualis Health Encounter Data Validation Results


Electronic

Data Checks

Full review of encounter data

submitted to the State indicates

no (or minimal) logic problems

or out-of-range values.

●Fully Met (pass) ●Fully Met (pass)

On-site

Clinical

Record

Review

State encounter data are

substantiated in audit of patient

charts at individual provider

locations. Audited fields include

demographics (name, date of

birth, ethnicity, and language)

and encounters (procedure

codes, provider type, duration



of service, service date, and

service location). A passing

score is that 95 percent of the

encounter data fields in the

clinical records match.

Electronic Data Checks

Qualis Health analysts reviewed all demographic details and encounters for KCBHO from ProviderOne for

the April 2016 through October 2016 reporting period, comprising 1,214,155 encounters and 70,401

patients. Fields for each encounter were checked for completeness and to determine if the values were

within expected ranges. Results of the electronic data checks are provided in Table E-3.

Table E-3: Results of Qualis Health’s Encounter Data Validation

Measure State Standard Mental Health Performance

SUD Performance

Demographic Data

BHO ID 100% complete, all values in range 100% 100%

Consumer ID 100% complete 100% 100%

First Name 100% complete 100% 100%

Last Name 100% complete 100% 100%

Date of Birth Optional 100% 100%

Gender Optional 100% 100%

Ethnicity/Race 100% complete, all values in range 100% 100%

Language Preference 100% complete, all values in range 100% 100%

Social Security Number

Optional 77% 92%

Sexual Orientation 100% complete 89% 94%

Encounter Data

BHO ID 100% complete, all values in range 100% 100%

Consumer ID 100% complete, all values in range 100% 100%

Agency ID 100% complete, all values in range 100% 100%

Primary Diagnosis 100% complete 100% 100%

Service Date 100% complete 100% 100%

Service Location 100% complete, all values in range 100% 100%

Provider Type 100% complete, all values in range 100% 100%

Procedure Code 100% complete 99% 100%

Claim Number 100% complete 100% 100%

Units of Service 100% complete 97% 100%


On-site Clinical Record Review Results

Qualis Health reviewed clinical charts for 134 individuals randomly selected from two mental health

agencies and 98 individuals randomly selected from four substance use disorder treatment agencies. For

each individual, Qualis Health reviewed up to six sequential encounters to determine the completeness

and accuracy of the data submitted to the State. The exact number of encounters and the encounter

initiating the reviewed sequence were selected using a random number generator in SAS 9.4. In all, 556

encounters were reviewed for mental health services, and 437 encounters were reviewed for substance

use disorder treatment services. Qualis Health reviewed encounter data fields required for review in the

BHO contract with DBHR, including:

date of service

name of service provider

procedure code

service units/duration

service location

provider type

verification that the service code agrees with the treatment described in the encounter

documentation

Additionally, Qualis Health reviewed all demographic fields delineated in the Behavioral Health Data

System native transaction, including:

first name

last name

gender

date of birth

ethnicity/race

Hispanic origin

preferred language

Social Security Number

sexual orientation

Results from these reviews are displayed in the following tables. Tables E-4 and E-5 show results of the

comparison of demographic data included in the clinical record to demographic data extracted from the

DBHR system.


Table E-4: Demographic Data Validation—Mental Health

Demographic Data (N = 134)

Field Match No Match— Erroneous

No Match— Missing

No Match— Unsubstantiated

Last Name 99% 1% 0% 0%

First Name 100% 0% 0% 0%

Gender 99% 1% 0% 0%

Date of Birth 100% 0% 0% 0%

Ethnicity/Race 87% 12% 0% 1%

Hispanic Origin 82% 14% 0% 4%

Preferred Language 4% 50% 37% 9%

Social Security Number 75% 0% 22% 3%

Sexual Orientation 49% 19% 8% 24%

Table E-5: Demographic Data Validation—SUD

Demographic Data (N = 98)


No Match— Missing


Last Name 97% 2% 1% 0%

First Name 99% 0% 1% 0%

Gender 97% 1% 1% 1%

Date of Birth 96% 2% 1% 1%

Ethnicity/Race 79% 17% 2% 2%

Hispanic Origin 85% 11% 2% 2%

Preferred Language 4% 37% 57% 2%

Social Security Number 83% 1% 13% 3%

Sexual Orientation 69% 8% 10% 12%

Results of the comparison of encounter data included in the clinical record to encounter data extracted

from the ProviderOne database are shown in Tables E-6 and E-7.

Table E-6: Encounter Data Validation—Mental Health

Encounter Data (N = 556)


No Match— Missing


Procedure Code 76% 16% 0% 8%

Date of Service 98% 0% 0% 2%

Service Location 92% 1% 0% 7%

Service Duration 76% 22% 0% 3%

Provider Type 76% 16% 0% 8%

Clinical Note Matches Procedure Code 64% 34% 0% 2%


Table E-7: Encounter Data Validation—SUD

Encounter Data (N = 437)


No Match— Missing


Procedure Code 47% 14% 0% 39%

Date of Service 64% 0% 0% 36%

Service Location 51% 9% 0% 39%

Service Duration 40% 24% 0% 36%

Provider Type 47% 14% 0% 39%

Clinical Note Matches Procedure Code 35% 29% 0% 36%

The comparison of the total match rate from the Qualis Health review to the total match rate from the

KCBHO internal EDV for demographic data is shown in Table E-8. Note: KCBHO did not report these

data, so Qualis Health is unable to present a comparison of results.

Table E-8: Comparison of Qualis Health and BHO Demographic Data Validation—Overall

Field Qualis Health

Match BHO

Match Variance

Last Name 98% NR NA

First Name 100% NR NA

Gender 98% NR NA

Date of Birth 98% NR NA

Ethnicity/Race 84% NR NA

Hispanic Origin 83% NR NA

Preferred Language 4% NR NA

Social Security Number 78% NR NA

Sexual Orientation 59% NR NA

The comparison of the total match rate from the Qualis Health review to the total match rate from the

KCBHO internal EDV for encounter data is shown in Table E-9. Note: KCBHO did not report these data,

so Qualis Health is unable to present a comparison of results.

Table E-9: Comparison of Qualis Health and BHO Encounter Data Validation—Overall

Field Qualis Health Match BHO Match Variance

Procedure Code 64% NR NA

Date of Service 83% NR NA

Service Location 74% NR NA

Service Duration 60% NR NA

Provider Type 64% NR NA

Clinical Note Matches Procedure Code 51% NR NA


Qualis Health's review found that in numerous cases, while data elements may have matched the

encounter, other elements of the encounter either did not follow the State’s SERI or WAC requirements,

contained insufficient documentation, did not match the code that was submitted, or did not reflect a

service that should have been submitted. Examples included the following:

Provider (upon instruction from the BHO) encountered location 12—residence when a client was

provided with methadone to take home, instead of location 57—Non-residential substance abuse

facility (as required by the SERI).

Non-encounterable activities were submitted, including writing and/or mailing a letter, writing a

treatment summary after the client had been closed to services without the client present, leaving

voicemail, checking messages, scheduling and rescheduling appointments, client no-showing

an appointment, calling in a medication refill.

SUD group documentation did not contain enough information to support the encounter duration.

CDPs did not sign off on CDPT progress notes or did not sign off on them in a timely manner.

Groups were encountered as H2027, H0036, and H0038, all of which are individual codes.

Clinicians did not date signatures, preventing assessment of timeliness of the documentation.

Documentation was written months after the service occurred, without explanation of why the

note was not written in a timely manner.

Documentation was cloned.

Bachelors-level interns and staff created individual service plans without MHP sign-off.

Provider type listed in the clinical note did not match the type listed in the State database.

Progress notes lacked a procedure code.

Family therapy did not contain a clinical intervention to support the encounter.

Clinicians did not sign with credentials.

H0019—mental health services in a residential setting was encountered when then clinician was

not present a minimum of 8 hours per day 7 days per week.

E&M documentation for 99214 did not contain all the required elements.

H0038 staff name did not include certified peer credentials.

Documentation that was lacking location information defaulted to code 99.

Regular outpatient codes were submitted for an individual in jail instead of a rehabilitation case

management code.

Case management encounters were submitted for case review when the client was not present.

The BHO submitted encounters on the behalf of agencies without evidence that a given individual

received a service for the day.


For all encounter fields, Qualis Health found a substantial level of disagreement between encounter data

extracted from ProviderOne and data included in the clinical record.

KCBHO needs to:

o use State data to capture duplicates and missing encounters, and ensure accuracy of data

submission

o work with its network on documentation standards to ensure that clinical interventions are

being well documented, which will enable KCBHO to match the correct code to the service

o train the BHAs on encounterable services and on providing documentation that indicates

treatment addressing behavioral health

o work with prescribing staff within the network on evaluation and management documentation

and rules


o train providers on documentation requirements, SERI requirements, and WAC requirements

for documentation and timeliness

111 Golden Thread

Golden Thread Focus Study

For the 2017 EQR focus study, Qualis Health examined the degree to which substance use disorder

(SUD) treatment providers’ clinical records demonstrated adherence to the “golden thread,” a series of

clear, consistent care linkages between an individual’s needs, diagnosis, and treatment. In evaluating

provider records, reviewers asked the following questions:

1. Does the individual’s assessment contain sufficient documentation to support the diagnosis, and

does it include all of the individual’s needs?

2. Are the documented needs reflected in specific goals in the treatment plan/individual service plan

(ISP)? Does the ISP address the individual’s diagnosis and all of the identified needs in the

assessment?

3. Do the progress notes address the individual’s treatment plan goals and the needs identified in

the assessment?

To answer these questions, Qualis Health reviewed 18 adult patient charts randomly selected from the

BHO’s EDV sample. Reviewers specifically evaluated documentation in three areas: assessments and re-

assessments, individual service planning, and progress notes. Each section (assessments/re-

assessments, ISPs, and progress notes) contained several subsections that were reviewed and scored.

These areas and the results of the review are discussed in the following section.

Summary of Results

Assessments

In reviewing clinical chart assessments, Qualis Health analyzed five different areas, evaluating how well

the chart documentation adhered to the following items presented in Table F-1.

Table F-1: Results for Review of Assessments in Clinical Charts

Criterion Percentage of charts meeting standard

1. Evidence of medical necessity based on the presence of a DSM-5 substance-related diagnosis

90.3%

2. Sufficient information within assessment to justify the diagnosis 67.7%

3. Recommendation(s) based on ASAM criteria 80.6%

4. Clear presentation of the individual’s concerns in the assessment 51.6%

5. Client voice present throughout the assessment 48.4%

Individual Service Plans

In reviewing individual service plans, Qualis Health analyzed eight different areas, evaluating how well the

chart documentation adhered to the following items presented in Table F-2.

112 Golden Thread

Table F-2: Results for Review of Individual Service Plans in Clinical Charts


1. All concerns in assessment are addressed in the service plan 25.8%

2. Service plan is individualized 80.6%

3.1. Service plan includes all substance use needing treatment, including tobacco

32.3%

3.2. Service plan includes the individual’s bio-psychosocial problems 54.8%

3.3. Service plan includes treatment goals 80.6%

3.4. Service plan includes estimated dates or conditions for completion of each treatment goal

45.2%

3.5. Service plan includes potential approaches to resolve identified problems

25.8%

4. Goals and/or objectives are measureable 3.2%

5. Interventions are aligned with the problems identified in the assessment 35.5%

6. If the individual service plan includes assignment of work to an individual, the assignment has therapeutic value

35.5%

7. The plan was updated to address applicable changes in identified needs, or as requested by the individual, at least once a month for the first three months and at least quarterly thereafter

9.7%

8. The plan was updated to identify achievement of goals and/or objectives

9.7%

Progress Notes

For the final portion of the Golden Thread review, Qualis Health examined whether or not the progress

notes indicated that the services provided were connected to the interventions, objectives, and goals

identified in the individual service plan resulting from the needs and concerns identified in the assessment

or reassessment process. This review area included seven criteria, presented in Table F-3.

Table F-3: Results for Review of Progress Notes in Clinical Charts


1. Progress notes were written in a timely manner in accordance with WAC 388-877B-0350

77.4%

2. Documentation clearly states the focus of each session 54.8%

3. Documentation clearly states the interventions described in the service plan

9.7%

4. Documentation describes the individual’s response to the intervention 25.8%

5. Interventions address the goals and objectives in the service plan 32.3%

6. Documentation indicates progress, or lack thereof, toward meeting the goals and objectives in the service plan

19.4%

7. Services provided align with the individual’s assigned level of care 51.6%

113 Golden Thread

Concluding Notes

During the clinical record review, reviewers noted a number of issues that may have contributed to lower

scores on the assessment. These include the following examples:

Assessment was not completed in a timely manner.

Clinical record did not contain evidence of an updated assessment or reassessment.

Assessments did not contain documentation that justified the diagnosis.

Assessments did not contain documentation of all of the individual's concerns.

Assessments did not contain treatment recommendations.

Assessments and ISPs were not present in the clinical record.

ISP did not indicate the services to be provided.

ISP did not include the frequency, duration, and scope/amount of services to be provided.

Goals did not contain timelines or conditions for completion.

Goals and/or objectives were not measureable.

Interventions included in the ISP resembled homework more so than interventions to be provided

by the clinician.

ISP was not updated to include new needs and goals.

ISP was not completed within the WAC timeframes.

ISP was not reviewed during the course of treatment.

ISP review occurred monthly but was never updated or changed.

Clinical records contained canned/cloned ISPs that were not specific to the individual.

Progress note content was not related to the needs identified in the assessment and the ISP.

Progress notes did not contain documentation of interventions.

Progress notes were written by the individual instead of the clinician.

Client was assessed as needing a higher level of care, but the facility lacked capacity to provide

the higher level of care immediately and did not provide services in the interim.

Group notes did not meet minimum documentation standards.

Documentation did not substantiate the duration of the service.

Case management reviews were submitted a year after the service occurred.

Clinic provided services to a client prior to completing the individual's ISP.

114 Golden Thread


115 Appendix

Appendix A: All Recommendations Requiring Corrective

Action Plans (CAPs)

Compliance with Regulatory and Contractual Standards






1. KCBHO needs to continue to work with the BHAs in developing successful talent management








2. KCBHO needs to follow up with the SUD treatment BHAs to ensure they have adopted and




3. KCBHO needs to implement a procedure to track requests for out-of-network services and use









4. KCBHO needs to update its credentialing policies and procedures to ensure all providers are


agreement.





5. In its policy on enrollee care coordination, KCBHO needs to include a definition or standard of


116 Appendix
















6. KCBHO needs to continue its monitoring efforts to ensure its BHAs have clearly defined care










7. KCBHO needs to ensure that all BHAs have treatment plans in place and that the treatment plans





healthcare needs.

8. The BHO needs to develop a policy and procedure regarding direct access to specialists for




9. KCBHO needs to add criteria to its monitoring tool to assess availability of direct access to

specialists.


N/A


117 Appendix




10. KCBHO needs to add criteria to its monitoring tool in order to review each BHA’s credentialing








11. KCBHO needs to ensure the BHO as well as the BHAs are performing exclusion checks on a






delegated services.

12. KCBHO needs to add language to its BHA contracts that clarifies that BHA subcontractors are




13. KCBHO needs to add delegation monitoring to its annual QA evaluation.





14. KCBHO needs to include in its policy the mechanism and frequency with which it distributes the






15. The BHO needs to create and implement a policy and procedure to ensure its BHAs are checking






letters

118 Appendix







16. KCBHO needs to continue to train and assist its SUD treatment BHAs to ensure the BHAs can


Section 8: Quality Assessment and Performance Improvement Program



State.

17. KCBHO needs to continue to monitor and support its SUD treatment BHAs in order to ensure it


Performance Improvement Project (PIP) Validation

PIP Validation Results: Clinical PIP


KCBHO did not state the focus of its study in the form of a question. While the BHO does provide

statements describing what it plans to achieve through the intervention, it is not posed in a clear, simple,

and answerable format.

18. KCBHO needs to formulate a study question that is truly in the structure of a question.

PIP Validation Results: Non-Clinical Children’s PIP

N/A

PIP Validation Results: Substance Use Disorder (SUD) PIP

N/A

Information Systems Capabilities Assessment (ISCA)


KCBHO’s business continuity and disaster recovery plans do not indicate frequency of periodic testing.

19. KCBHO needs to periodically test its BC/DR plans. The plans should indicate the frequency of

testing and the type of testing performed.


The BHO policy for disabling inactive accounts is to disable an account after one year of inactivity; the

NIST standard is for 60 days.

119 Appendix

20. KCBHO needs to modify its policy to disable inactive accounts after 60 days.

Encounter Data Validation (EDV)


KCBHO did not clearly document the number of client charts selected for its sample in its DBHR

deliverable, so it was not possible to determine whether the BHO met its contract-required minimum of

selected encounters.

21. KCBHO should clearly state the number of client charts selected for its sample within its

deliverable to DBHR.


KCBHO did not submit a copy of its review tool in its State deliverable, which is a contract requirement

and would facilitate a more effective review of the tool.

22. KCBHO needs to submit a copy of its review tool in its DBHR deliverable.


In a repeat finding from the 2016 EQR, KCBHO’s review tool did not include fields for all of the DBHR-

required elements; specifically, “service code agrees with treatment described” was not present in the

Excel spreadsheet tool.

23. KCBHO needs to include all contract-required elements in its review tool.


KCBHO reported only aggregate results for each agency, whereas the BHO-DBHR contract requires

analysis and reporting of the error rate for each data element. This was a repeat finding from the 2016

EQR.

24. KCBHO needs to provide the error rates for all data elements in its State deliverable.


For all encounter fields, Qualis Health found a substantial level of disagreement between encounter data

extracted from ProviderOne and data included in the clinical record.

25. KCBHO needs to:

o use State data to capture duplicates and missing encounters, and ensure accuracy of data

submission

o work with its network on documentation standards to ensure that clinical interventions are

being well documented, which will enable KCBHO to match the correct code to the service

o train the BHAs on encounterable services and on providing documentation that indicates

treatment addressing behavioral health

o work with prescribing staff within the network on evaluation and management documentation

and rules

o train providers on documentation requirements, SERI requirements, and WAC requirements

for documentation and timeliness

120 Appendix

Appendix B: Review of Previous-Year Recommendations

Requiring Corrective Action Plans (CAPs)

As part of the 2017 EQR activities, Qualis Health reviewed the previous-year recommendations BHOs

received in areas of compliance with State and federal regulatory standards, performance improvement

project validation, and encounter data validation. The BHO’s recommendations and its progress to date

implementing the accompanying corrective action plans are presented below.

CFR/Review

Area

2016 QH Recommendation/

DBHR CAP

BHO Activity Since the Prior

Year

Current Status

438.228 (a),(b)

Grievance

Systems

KCBHO received only one

grievance in the first quarter of

2016. This seems highly unlikely

given the size of the population of

King County. The BHO did state

that the BHAs and the Ombuds

only ask for written grievances,

not for oral grievances, and also

stated that the BHO and its BHAs

are not recording all complaints of

dissatisfaction. Interviews with the

BHAs indicated there were

concerns and grievances voiced

by enrollees that had not been

logged and provided to the BHO.

KCBHO needs to re-educate the

BHAs, the Ombuds and its own

staff on what constitutes a

grievance: all expressions of

dissatisfactions. All grievances

need to be recorded and logged

and provided to the BHO

quarterly. Grievances should then

be tracked and trended for quality

improvement purposes.

Grievances should also be

reviewed and analyzed by the

BHO’s quality improvement

committee and compliance

committee to identify

opportunities for improvement as

well as potential areas of risk.

The BHO intends to continue to

communicate and provide

training to its staff and the

BHAs about logging grievances

and submitting quarterly

grievance reports.

Resolved.

438.228 (a),(b)

Grievance

Systems

The BHO stated that a

methodology for logging all

grievances has not been

established with all of the BHAs.

The BHO has provided and

stated it intends to continue

providing training to its staff and

the BHAs about logging

Resolved.

121 Appendix

KCBHO needs to work with the

BHAs to establish a methodology

for recording and logging all

grievances received by the BHAs.

The BHAs then need to submit all

logs quarterly to the BHO.

grievances and submitting

quarterly grievance reports.

438.416

Recordkeeping

and Reporting

Although the BHO requires the

BHAs to file grievances

separately from clinical records,

ensure the grievances are locked

in a secure file cabinet or

electronic file, ensure grievances

are kept for at least six years, and

ensure that only people who need

to know have access to the

grievances; there is no formal

written policy and procedure

detailing these requirements.

KCBHO needs to develop a

record retention policy and

procedure that includes the above

requirements.

The current KCBHO Policy and Procedure, Section XI. Grievance System: 3.2.8 states: “G. Full records of all

grievances and materials

received or compiled in the

course of processing and

attempting to resolve the

grievance are maintained and:

1. Kept for six years after

the completion of the

grievance process;

ADD KC Record

Retention Reference…

2. Made available to

Department of Social

and Health Services

(DSHS) upon request

as part of the State

Quality Strategy;

3. Kept in confidential files

separate from the

individual’s clinical

record; and

4. Not disclosed without

the individual’s written

permission, except to

DSHS or as necessary

to resolve the

grievance.”

Resolved.

438.600

Provider

Eligibility

KCBHO’s policy and procedure

ensures staff are not listed by the

Office of the Inspector General

(OIG) as debarred, excluded or

otherwise ineligible for Federal

program participation, as required

by Federal or State laws, or found

to have a conviction or sanction

related to healthcare as listed in

the Social Security Act, Title 11.

However, the policy and

Section 4.0 of KCBHO’s

program integrity policy

includes the language:

“Providers shall report to the

KCBHO and the KCBHO shall

report to Washington State

Division of Social and Health

Services (DSHS):

4.4.1. Any excluded individuals

and entities discovered in the

Resolved.

122 Appendix

procedure does not specifically

include the BHO’s intention to

report to DSHS within 10

business days any excluded

individuals or entities discovered

in the OIG screening process.

KCBHO needs to add to its policy

and procedure its intention to

report to DSHS within ten

business days any excluded

individuals and entities

discovered in the OIG excluded

checks.

screening within 10 business

days.”

438.602

Data

Certification

On April 1, 2016, KCBHO

developed an internal policy and

procedure that states: “The BHO

will establish policies and

procedures that address data

quality, assure certification occurs

concurrently with the submission

of data to the State, develop

protocols for data certification and

instructions of how to submit the

data, and maintain internal

records of certifications.” The

policy does not include ensuring

the BHAs are also attesting to the

quality and integrity of data being

submitted to the BHO.

The BHO needs to create an

external policy and procedure to

ensure its BHAs are checking

their data for quality and integrity

before the data are submitted to

the BHO.

The BHO intends to:

revise its policies to include the requirement for providers to submit a written attestation of data accuracy

develop a form letter for providers to complete, attesting to data accuracy

inform providers of change and seek additional input on the KCBHO process

design and implement a system for letters to be transmitted electronically to KCBHO

have contract monitors follow up on attestation letter submissions

In progress.

438.606

Source,

Content and

Timing of

Certification

The BHO does not maintain

internal logs of attestations in

accordance with its internal policy

and procedure.

KBHO needs to create a log of

attestations to formalize its

emailed attestation and data

transaction submissions, and

keep this on file per record

retention guidelines.

The BHO has updated its policy

to include a log of attestations

and intends to store the

attestations in a shared folder.

Resolved.

123 Appendix

438.608 (a)(b)

Program

Integrity

Requirements

KCBHO has not been performing

annual risk assessments.

The BHO needs to perform risk

assessments annually, and

discuss the results with its

executive team, board and

appropriate committees. The

discussions should include

developing action plans to

regularly monitor risks and

vulnerable areas, and seek

interventions where appropriate

to mitigate risks. Additionally, the

team needs to include the results

of the annual risk assessment in

its annual compliance self-

evaluation.

The BHO indicated that it will

include the annual performance

of risk assessments in its

compliance plan. However, the

BHO is not yet annually

performing risk assessments.

The BHO indicated that it will

initiate a risk assessment after

it hires a compliance officer.

While on-site, the EQRO

provided extensive technical

assistance for this

recommendation.

In progress.

438.608 (a)(b)

Program

Integrity

Requirements

Although the county has a code

of ethics summary, the BHO does

not have its own documented

code of ethics/standards of

conduct nor does it have a

mechanism in place to monitor

attestations of its own staff and

contracted entities.

KCBHO needs to adopt its own

code of ethics/conduct and

develop a policy and procedure

for ensuring its own

staff/contracted entities are

adhering to the code of

ethics/conduct. The BHO could

include training on the code of

ethics in its annual compliance

training program for its BHO staff

and board, and its BHAs.

During the first quarter of 2017,

KCBHO reviewed the current

King County Code of Ethics

and, as needed, revised it to

incorporate any additional

requirements as defined in CFR

438. Additionally, KCBHO

reviewed and, as needed,

developed a policy to describe

staff adherence and training for

the code of ethics. The policy

addresses the inclusion of the

code of ethics in the annual

compliance training program for

BHO and BHA staff.

The KCBHO Compliance Plan

includes references to the King

County Code of Ethics. All

county employees are expected

to adhere to this policy, and

KCBHO documents require

adherence to this county

standard.

Training will include

reaffirmation/ acknowledgment

of the King County Code of

Ethics. Additionally, identified

county staff must also complete

Resolved.

124 Appendix

the King County COI

attestation. The BHO indicated

it will begin monitoring its BHAs

to ensure they maintain a code

of ethics.

The EQR staff provided

technical assistance during the

on-site interview regarding this

recommendation.

438.608 (a)(b)

Program

Integrity

Requirements

KCBHO indicated it was uncertain

of whether its new employee

orientation covered training on

whistleblower protections.

KCBHO needs to ensure training

on its policy and procedure

related to whistleblower

protections, which includes no

retaliation, is provided in its new

employee orientation and in the

annual compliance training

program.

KCBHO has affirmed that its

compliance training includes

whistleblower protections.

Resolved.

438.608 (a)(b)

Program

Integrity

Requirements

KCBHO does not keep a formal

log of reports of suspected fraud,

waste and abuse.

The BHO needs to develop a

formal tracking process for all

reports of suspected fraud, waste

and abuse in order to ensure it

has effective lines of

communication between the

compliance officer and the

organization’s employees. This

formal log should be reviewed by

the compliance committee and

incorporated into the committee’s

meeting agenda as a standing

agenda item.

KCBHO has developed a

centralized process for tracking

all reports of suspected fraud,

waste, and abuse as part of the

overall KCBHO compliance

plan.

Resolved.

438.608 (a)(b)

Program

Integrity

Requirements

The BHO does not review

grievance and critical incident

data, including data from the

providers and the Ombuds, or

complaints from contractors and

community members, for specific

incidents or trends that may

indicate fraud and abuse.

KCBHO intends to incorporate

review of grievance and critical

incident data into its ongoing

Quality Improvement

Committee agenda. The review

process has been included in

the overall KCBHO Compliance

Plan.

Resolved.

125 Appendix

The KBHO needs to develop a

process and procedure to review

grievance and critical incident

data, including data from the

providers and the Ombuds and

complaints from contractors and

community members, for specific

incidents or trends that may

indicate fraud and abuse.

438.608 (b)

Compliance

Programs

KCBHO’s compliance officer

indicated the BHO utilizes the

Plan Management Group (PMG)

as its compliance committee. This

committee doesn’t have a formal

charter, routine agendas or

meeting minutes.

The BHO needs to develop a

formal charter and compliance

committee that convenes at least

quarterly, if not monthly. The

charter needs to indicate the

duties of the compliance

committee, its members, and the

frequency of meetings. The

compliance committee should

follow a formal agenda with

reportable meeting minutes in

order to reflect the oversight of its

compliance program.

KCBHO has produced a draft of

a written compliance plan,

which has undergone first-level

review by the BHO’s contracts

manger, quality manager,

managed care specialist, and

BHO administrator. The plan

will next be reviewed by

executive leadership.

In progress.

438.608 (b)

Compliance

Programs

KCBHO’s compliance officer

indicated that division-wide

compliance training has not been

conducted on an annual basis.

The BHO needs to ensure it

provides annual compliance

training for its BHO staff,

governing board and its

delegated entities.

KCBHO reported that initial

compliance training for all BHO

staff will be completed by June

30, 2017.

In progress.

431.107

Record

Retention

The BHO follows the record

retention policy and procedure

used by the county, and does not

have its own policy and

procedure.

KCBHO needs to create a BHO-

KCBHO has initiated discussion

with the King County archivist

and records and information

manager to review and

incorporate specific record

retention requirements into the

King County Record Retention

In progress.

126 Appendix

centric policy and procedure

related to record retention, and

ensure its BHAs have a record

retention policy that mirrors the

BHO policy.

Schedule. The proposed

timeline is 4–6 months.

This will include the new ten-

year record retention

requirements for records

specified in 42 CFR Part 438.3.

431.107

Record

Retention

KCBHO’s administrative audit tool

does not include annual

monitoring of its delegated

entities for record retention.

KCBHO needs to update its

administrative audit tool to include

annual monitoring of its delegated

entities for record retention,

including but not limited to

credentialing and re-credentialing,

incident reporting, requests for

services, authorizations, clinical

records, complaints, grievances,

appeals, referrals for fraud, waste

and abuse, and outcomes of

fraud, waste and abuse.

KCBHO has included

monitoring of its delegated

entities for record retention in

its policy Monitoring: Monitoring

Plans for BHAs.

Resolved.

455.100

Excluded

Entities

Section 4 of the BHO’s program

integrity policy references

excluded provider checks but

doesn’t include information

regarding the requirement to

perform checks on a monthly

basis not only for new staff but

also for existing staff, or to

maintain a formal monthly log for

monitoring and reporting

purposes.

KCBHO should update its

program integrity policy to include

language regarding the

requirement to perform monthly

exclusion checks on all staff and

add language that it will retain a

formal monthly log for monitoring

and reporting purposes.

KCBHO is currently revising its

process for excluded providers,

which will be completed by

June 30, 2017. An active list of

all staff, including department

management, will be included

in initial and ongoing monthly

screenings. The active list will

be available for review at future

EQR site visits. The program

integrity policy and procedure

will be reviewed and, as

needed, revised to incorporate

this process by June 30, 2017.

In progress.

Performance

Improvement

Project (PIP)

Validation:

Non-Clinical

The BHO has not fully followed

through on last year’s

recommendation to fully formulate

and begin this PIP.

KCBHO has fully formulated

this PIP and have moved

beyond the initial phases. The

BHO has revised its data

sharing approach and has

Resolved.

127 Appendix

PIP KCBHO needs to clearly state its

interventions as well as clear

criteria for how it will determine

which intervention will be

implemented for which youth.

KCBHO needs to begin collecting,

reporting and analyzing data for

youth dually enrolled in the BHO

and Molina Apple Healthcare plan

as stated by the BHO in its PIP

study question.

identified the intervention

(CCORS or Wraparound)

based on the needs of the

enrollee.

KCBHO has been successful in

collecting the data from Molina

and has identified a care

coordination process to be used

for the youth involved in this

PIP.

Due to the previous difficulties

in obtaining data, KCBHO no

longer uses the monthly BHO-

to-MCO data files and MCO-to-

BHO data files.

Performance

Improvement

Project (PIP)

Validation:

Non-Clinical

PIP

KCBHO has noted Wraparound

and CCORS as possible

interventions for youth involved in

this PIP. The BHO has not set a

clear plan how it will be

determined which youth will

receive which intervention.

KCBHO needs to clearly

articulate its criteria for

determining which intervention a

youth will receive if they are

involved in this PIP.

The BHO has revised its data

sharing approach and has

identified the intervention

(CCORS or Wraparound)

based on the needs of the

enrollee.

The revised intervention

includes an information

systems component of sharing

the care plan and patient

records on EDIE/PreManage

for the BHO and Molina and

providers to access.

Resolved.

Performance

Improvement

Project (PIP)

Validation:

Non-Clinical

PIP

While there is value in continually

striving to work to obtain data

from all of the MCOs, this does

not have to be completed in

conjunction with a PIP. KCBHO

has been in the beginning stages

of this PIP for multiple years,

without collecting and analyzing

data from a single MCO, including

Molina.

KCBHO needs to begin the work

of this PIP. KCBHO needs to

collect and analyze the data it

proposes to aggregate and

interpret for enrollees it shares

with Molina Apple Health and

KCBHO has revised its data

collection strategies and is

focusing on collaborating with

Molina at this time. The BHO

has made strides in obtaining

and sharing data with Molina on

dually enrolled enrollees.

Resolved.

128 Appendix

investigate if its proposed

intervention will achieve the

desired outcome.

129 Appendix

Appendix C: Readiness Assessment Follow-up

As a part of the 2016 EQR, Qualis Health assessed each BHO’s status in integrating SUD treatment

agencies into the BHO structure. Reviewers conducted SUD provider interviews, as well as SUD provider

agency walkthroughs. The following table presents the observations and opportunities for improvement

identified during those review activities, as well as Qualis Health’s 2017 follow-up of the BHO’s progress

in addressing those items.

Opportunity for Improvement BHO Progress Since 2016

Review

Status

Employee Conduct

At one SUD agency, visitors

were not required to sign in or

review the confidentiality notice

posted on the wall in the lobby,

nor were they given visitor

badges. At this SUD provider

agency, the employees were not

wearing identification badges.

While performing the on-site

walkthrough of the provider

facility, Qualis Health was unable

to distinguish outside guests and

enrollees from employees.

KCBHO did not follow up with the

agency.

Opportunity remains.

Workstation Use

At one agency, workstations and

computer monitors were not

positioned to prevent

unauthorized persons from

viewing ePHI.


agency.


At one agency, unattended

computers are not returned to the

logon screen (automatically

or by user) or have password-

enabled screensavers when not

in use.


agency.


Access Controls

N/A

Environmental Controls

At one agency, server equipment

was not stationed away from

sprinklers and other water

supplies.


agency.


Enrollee Rights and Grievances

Enrollee rights were posted but

were out of date, and SUD

providers were unaware of how


agencies.


130 Appendix

often and by what means the

BHO informs enrollees about

their rights, responsibilities and

benefits. ADA Requirements

One facility did not meet ADA

accessibility requirements for

individuals with physical

disabilities. Although the

sidewalk leading up to the front

entrance was accessible, the

door had to be opened manually.

The SUD director stated that

anyone in a wheelchair trying to

gain access to the building would

need to wait outside until

someone noticed the person

waiting. The lobby was on the

second floor, so the client would

either have to wait for another

client to help or wait for an SUD

public safety officer to open the

door.


agency.


Medication Monitoring

N/A

Seclusion and Restraint

One provider stated that with

regard to seclusion and restraint,

the agency engaged in a “hands-

off policy.” However, the agency

had no written policy in place

indicating the provider didn’t

engage in seclusion or restraint,

and the provider had not adopted

the BHO’s policy indicating the

provider doesn’t engage in

seclusion and restraint.


agency.


Miscellaneous Environment of Care

At one provider, poisonous

chemicals or caustic materials

were not safely stored and

locked up.


agency.


At one provider, no visible

evacuation plans and maps of

evacuation routes were posted in

the lobby.


agency.


131 Appendix

132 Appendix

Appendix D: Coordination of Care Clinical Chart Review

Results and Scoring Definitions

42 CFR §438.208—Coordination and continuity of care specifies that “each MCO, PIHP, and PAHP” (the

BHO, as applied to this review) must implement procedures to deliver care and coordinate services for all

enrollees. These procedures must meet State requirements and must do the following:

ensure the BHO has and implements a policy and procedure for delivering care and coordinating

healthcare services for all enrollees

ensure enrollees have an ongoing source of care appropriate for their needs and access to

providers responsible for coordinating their care and services

ensure that each enrollee has access to a primary healthcare provider appropriate to the

enrollee’s needs

ensure the BHO has a process in place to communicate enrollees’ healthcare needs with other

service providers to prevent duplication of activities

ensure the BHO has a process in place with its BHAs to monitor care coordination and other

healthcare services furnished to enrollees

To assess the degree of coordination of care at the BHO’s behavioral health agencies (BHAs), Qualis

Health completed 17 clinical chart reviews evaluating coordination of care at two agencies. Although this

activity was not completed for all of the BHO’s contracted providers, it does provide a snapshot of the

care provided by the two agencies where charts were reviewed. The results of this assessment for

KCBHO are presented in the table below.

Clinical Record Review: N=17 charts

Number of charts in which the intake assessment included:

the name of the individual’s treatment supporters

9/17

o substance use disorder treatment provider

0

o school staff/teacher 3

o Aging and Long-Term Support Administration

0

o tribes 0

o physician/psychiatrist 9

o criminal justice 0

o Offender Re-entry Community Safety Program

0

o Children's Administration 0

o Department of Corrections 0

133 Appendix

o Division of Vocational Rehabilitation

0

o other 5

a description of concerns 13

medications currently taken 5

Number of charts in which the individual service plan included:

a plan to coordinate care with relevant treatment supporters

4/17

Number of charts in which the clinical record contained:

documentation of coordination 9/17

o a description of care coordination in progress note

10

o correspondence with supporters 8

o documentation received from supporters

2

o release of information for supporters

10

medication records, if applicable 1

(5 N/A)

laboratory records, if applicable 0

(11 N/A)

Overall scoring

Number of charts in which the clinical record reflects:

very good care coordination 1

good care coordination 2

fair care coordination 3

poor care coordination 1

very poor care coordination 10

Scoring Definitions

“Very good care coordination” means the clinical record reflects consistent, active coordination of care

with treatment supporters. Concerns and/or conditions are clearly identified, and the individual service

plan addresses coordination of care with relevant supporters. There is evidence of effective

communication flow between the behavioral health provider and treatment supporters.

134 Appendix

“Good care coordination” means the clinical record reflects coordination of care with treatment

supporters. Concerns are clearly identified, and the individual service plan addresses coordination of care

with relevant supporters. There is evidence of communication between the behavioral health professional

and treatment supporters, but it is not of sufficient consistency or quality to substantiate a higher rating.

“Fair care coordination” means the clinical record reflects only a moderate level of care coordination with

treatment supporters. Concerns and/or conditions are not clearly identified, or identified concerns and/or

conditions are not adequately addressed in the individual service plan. The record contains some

evidence of communication between the behavioral health and treatment supporters, but it is either

inconsistent or the content is questionably meaningful.

“Poor care coordination” means the clinical record reflects minimal care coordination.

Concerns/conditions are not clearly identified, and/or the individual service plan does not address medical

issues. The record may contain some evidence of communication between behavioral health providers

and treatment supporters, but it is generally administrative in nature.

“Very poor coordination” means the clinical record contains no evidence of care coordination with

treatment supporters. Concerns and/or conditions are not identified. The individual service plan does not

address concerns. The record contains no evidence of communication between behavioral health

providers and treatment supporters.

135 Appendix

Appendix E: Regulatory and Contractual Standards

Following are the regulatory standards cited in the Code of Federal Regulations (CFR) that BHOs are

required to meet, as well as the applicable elements of the BHOs’ contract with DBHR. The standards are

followed by the corresponding scoring criteria Qualis Health’s review team used to assess the BHOs on

their compliance with these standards. The results of that assessment are reflected in the compliance

chapter of this report.

Availability of Services §438.206 Availability of services.

(a) Basic rule. Each State must ensure that all services covered under the State plan are available and

accessible to enrollees of MCOs, PIHPs, and PAHPs in a timely manner. The State must also ensure that

MCO, PIHP and PAHP provider networks for services covered under the contract meet the standards

developed by the State in accordance with §438.68.

(b) Delivery network. The State must ensure, through its contracts, that each MCO, PIHP and PAHP,

consistent with the scope of its contracted services, meets the following requirements:

(1) Maintains and monitors a network of appropriate providers that is supported by written agreements

and is sufficient to provide adequate access to all services covered under the contract for all enrollees,

including those with limited English proficiency or physical or mental disabilities.

§438.68 Network adequacy standards.

(a) General rule. A State that contracts with an MCO, PIHP or PAHP to deliver Medicaid services must

develop and enforce network adequacy standards consistent with this section.

(b) Provider-specific network adequacy standards. (1) At a minimum, a State must develop time and

distance standards for the following provider types, if covered under the contract:

(i) Primary care, adult and pediatric.

(iii) Behavioral health (mental health and substance use disorder), adult and pediatric.

(iv) Specialist, adult and pediatric.

(v) Hospital.

(vi) Pharmacy.

(viii) Additional provider types when it promotes the objectives of the Medicaid program, as determined by

CMS, for the provider type to be subject to time and distance access standards.

(3) Scope of network adequacy standards. Network standards established in accordance with paragraphs

(b)(1) and (2) of this section must include all geographic areas covered by the managed care program or,

if applicable, the contract between the State and the MCO, PIHP or PAHP. States are permitted to have

varying standards for the same provider type based on geographic areas.

(c) Development of network adequacy standards. (1) States developing network adequacy standards

consistent with paragraph (b)(1) of this section must consider, at a minimum, the following elements:

(i) The anticipated Medicaid enrollment.

(ii) The expected utilization of services.

(iii) The characteristics and health care needs of specific Medicaid populations covered in the MCO,

PIHP, and PAHP contract.

(iv) The numbers and types (in terms of training, experience, and specialization) of network providers

required to furnish the contracted Medicaid services.

(v) The numbers of network providers who are not accepting new Medicaid patients.

(vi) The geographic location of network providers and Medicaid enrollees, considering distance, travel

time, the means of transportation ordinarily used by Medicaid enrollees.

136 Appendix

(vii) The ability of network providers to communicate with limited English proficient enrollees in their

preferred language.

(viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally

competent communications, and accessible equipment for Medicaid enrollees with physical or mental

disabilities.

(ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or

other evolving and innovative technological solutions.

(2) States developing standards consistent with paragraph (b)(2) of this section must consider the

following:

(i) All elements in paragraphs (c)(1)(i) through (ix) of this section.

(ii) Elements that would support an enrollee's choice of provider.

(iii) Strategies that would ensure the health and welfare of the enrollee and support community integration

of the enrollee.(d) Exceptions process. (1) To the extent the State permits an exception to any of the

provider-specific network standards developed under this section, the standard by which the exception

will be evaluated and approved must be:

(i) Specified in the MCO, PIHP or PAHP contract.

(ii) Based, at a minimum, on the number of providers in that specialty practicing in the MCO, PIHP, or

PAHP service area.

(2) States that grant an exception in accordance with paragraph (d)(1) of this section to a MCO, PIHP or

PAHP must monitor enrollee access to that provider type on an ongoing basis and include the findings to

CMS in the managed care program assessment report required under §438.66.

(e) Publication of network adequacy standards. States must publish the standards developed in

accordance with paragraphs (b)(1) and (2) of this section on the Web site required by §438.10. Upon

request, network adequacy standards must also be made available at no cost to enrollees with disabilities

in alternate formats or through the provision of auxiliary aids and services.

State Regulation/BHO Agreement Sources

WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 10.9.3.3, 5.8.4, 5.8.5, 5.12, 10.4.13

EQR Scoring Criteria

The BHO maintains and monitors an appropriate network of BHAs that is supported by

written agreements.

The BHO’s BHA network is sufficient to provide adequate access to all services covered

under the contract.

The BHO annually conducts geo mapping that includes the cultural, ethnic, racial, and

linguistic needs of its members; distance; travel time; the means of transportation

ordinarily used by Medicaid enrollees; and whether the location provides physical access

for Medicaid enrollees with disabilities.

In establishing and maintaining the network, the BHO considers:

o the anticipated Medicaid enrollment

o the expected utilization of services, taking into consideration the characteristics and

healthcare needs of specific Medicaid populations represented in the BHO

o the numbers and types (training, experience, and specialization) of BHAs required to

furnish the contracted Medicaid services

o the number of network BHAs that are not accepting new Medicaid patients

The BHO has formal procedures in place to monitor its BHA network to ensure adequacy.

137 Appendix

§438.206 Availability of services.



(3) Provides for a second opinion from a network provider within the network, or arranges for the enrollee

to obtain one outside the network, at no cost to the enrollee.

State Regulation/BHO Agreement Source(s)

WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 10.9.3.3, 11.11


The BHO maintains policies and procedures related to second opinions that meet the

contract and WAC standards.

BHO staff are knowledgeable about State and federal requirements, as well as internal

policies and procedures.

The BHO provides literature or other materials available to enrollees to provide

information about the enrollee’s right to a second opinion.

The BHO provides for a second opinion from a qualified healthcare professional within

the network, or arranges for the enrollee to obtain one outside the network, at no cost to

the enrollee.

The BHO has an effective process in place to monitor compliance with standards.




(4) If the provider network is unable to provide necessary services, covered under the contract, to a

particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of

network for the enrollee, for as long as the MCO, PIHP, or PAHP's provider network is unable to provide

them.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 10.9.3.3, 15.3, 15.4


The BHO provides documentation of adequate and timely covered services for out-of-

network enrollees when the network is unable to provide necessary services covered

under the contract.

The BHO provides up-to-date existing agreements and/or contracts with out-of-network

providers.

The BHO has a process to track out-of-network encounters and reviews this information

for network capacity planning.




138 Appendix

(5) Requires out-of-network providers to coordinate with the MCO, PIHP, or PAHP for payment and

ensures the cost to the enrollee is no greater than it would be if the services were furnished within the

network.

State Regulation/BHO Agreement Sources

WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 15.3, 15.4


The BHO has a documented process and policy that require out-of-network providers to

coordinate with the BHO with respect to payment.

The BHO has a documented process for how out-of-network providers are paid.

The BHO ensures and has a documented policy and process that cost to the enrollee is

not greater than it would be if the out-of- network services were furnished within the

network.

The BHO has a process for the action taken if an enrollee receives a bill for out-of-

network services.




(6) Demonstrates that its network providers are credentialed as required by §438.214.

§438.214 Provider selection.

(a) General rules. The State must ensure, through its contracts, that each MCO, PIHP, or PAHP

implements written policies and procedures for selection and retention of network providers and that

those policies and procedures, at a minimum, meet the requirements of this section.

(b) Credentialing and recredentialing requirements. (1) Each State must establish a uniform

credentialing and recredentialing policy that addresses acute, primary, behavioral, substance use

disorders and requires each MCO, PIHP and PAHP to follow those policies.

(2) Each MCO, PIHP, and PAHP must follow a documented process for credentialing and

recredentialing of network providers.

(c) Nondiscrimination. MCO, PIHP, and PAHP network provider selection policies and procedures,

consistent with §438.12, must not discriminate against particular providers that serve high-risk

populations or specialize in conditions that require costly treatment.

(d) Excluded providers. (1) MCOs, PIHPs, and PAHPs may not employ or contract with providers

excluded from participation in federal health care programs under either section 1128 or section

1128A of the Act.

(c) [Reserved]

(e) State requirements. Each MCO, PIHP, and PAHP must comply with any additional requirements

established by the State.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 8, 8.5


The BHO has a documented process and policy to ensure that out-of-network providers are

appropriately credentialed.

139 Appendix


(c) Furnishing of services. The State must ensure that each MCO, PIHP and PAHP contract complies with

the requirements:

(1) Timely Access. Each MCO, PIHP and PAHP must do the following:

(i) Meet and require its providers to meet State standards for timely access to care and

services, taking into account the urgency of the need for services.

(ii) Ensure that the network providers offer hours of operation that are no less than the hours of

operation offered to commercial enrollees or comparable to Medicaid FFS, if the provider

serves only Medicaid enrollees.

(iii) Make services included in the contract available 24 hours a day, 7 days a week, when

medically necessary.

(iv) Establish mechanisms to ensure compliance by network providers.

(v) Monitor network providers regularly to determine compliance.

(vi) Take corrective action if there is a failure to comply by a network provider.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 10.9.3.2


The BHO has and implements a policy for timely access.

The BHO requires its providers to meet State Medicaid standards for timely access to

care and services.

The BHO ensures that the network BHAs offer hours of operation that are no less than

the hours of operation offered to commercial enrollees or comparable to Medicaid fee-for-

service, if the BHA serves only Medicaid enrollees.

The BHO has established mechanisms to ensure services included in the contract are

available 24 hours a day, 7 days a week, when medically necessary.

The BHO takes corrective action and has documentation of such corrective action if BHAs fail to

comply with access standards.


(c) Furnishing of services. The State must ensure that each MCO, PIHP and PAHP contract complies with

the requirements:

(2) Access and cultural considerations. Each MCO, PIHP, and PAHP participates in the State's efforts

to promote the delivery of services in a culturally competent manner to all enrollees, including those

with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and

regardless of gender, sexual orientation or gender identity.

(3) Accessibility considerations. Each MCO, PIHP, and PAHP must ensure that network providers

provide physical access, reasonable accommodations, and accessible equipment for Medicaid

enrollees with physical or mental disabilities.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 5.8.5.4, 10.9.3.4, 11.4.2.2, 11.9, 12.6.1.4


140 Appendix

The BHO has a documented policy and procedure related to the delivery of services in a

culturally competent manner to all enrollees, including those with limited English

proficiency and diverse cultural and ethnic backgrounds.

The BHO monitors and has documented tracking of the delivery of services to those with

limited English proficiency and diverse cultural and ethnic backgrounds.

The BHO has documentation of any cultural competency training(s).

The BHO has a documented policy and procedure related to accessibility considerations

to ensure that BHAs provide physical access, reasonable accommodations, and

accessible equipment for Medicaid enrollees with physical or mental disabilities.

The BHO monitors its BHAs to ensure they provide adequate physical access,

reasonable accommodations, and accessible equipment for Medicaid enrollees with

physical or mental disabilities.

Coordination of Care §438.208 Coordination and continuity of care.

(b) Care and coordination of services for all MCO, PIHP, and PAHP enrollees. Each MCO, PIHP, and

PAHP must implement procedures to deliver care to and coordinate services for all MCO, PIHP, and

PAHP enrollees. These procedures must meet State requirements and must do the following:

(1) Ensure that each enrollee has an ongoing source of care appropriate to his or her needs and a person

or entity formally designated as primarily responsible for coordinating the services accessed by the

enrollee. The enrollee must be provided information on how to contact their designated person or entity;

(2) Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee:

(i) Between settings of care, including appropriate discharge planning for short term and long-term

hospital and institutional stays;

(ii) With the services the enrollee receives from any other MCO, PIHP, or PAHP;

(iii) With the services the enrollee receives in FFS Medicaid; and

(iv) With the services the enrollee receives from community and social support providers.

(3) Provide that the MCO, PIHP or PAHP makes a best effort to conduct an initial screening of each

enrollee's needs, within 90 days of the effective date of enrollment for all new enrollees, including

subsequent attempts if the initial attempt to contact the enrollee is unsuccessful;

(4) Share with the State or other MCOs, PIHPs, and PAHPs serving the enrollee the results of any

identification and assessment of that enrollee's needs to prevent duplication of those activities;

(5) Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an

enrollee health record in accordance with professional standards.


BHO Agreement Section(s) 10.3.1


The BHO must have and implement a policy and procedure for delivering care and coordinating

healthcare services for all enrollees.

The BHO must ensure enrollees have an ongoing source of care appropriate for their needs and

access to providers responsible for coordinating enrollees’ care and services.

The BHO ensures that each enrollee has access to a primary healthcare provider appropriate to

the enrollee’s needs.

The BHO has a process in place to communicate enrollees’ healthcare needs with other service

providers to prevent duplication of activities.

The BHO has a process in place to monitor care coordination and other healthcare services

141 Appendix

furnished to enrollees with its BHAs.

§438.208 Coordination and continuity of care.

b) Care and coordination of services for all MCO, PIHP, and PAHP enrollees. Each MCO, PIHP, and

PAHP must implement procedures to deliver care to and coordinate services for all MCO, PIHP, and

PAHP enrollees. These procedures must meet State requirements and must do the following:

(6) Ensure that in the process of coordinating care, each enrollee's privacy is protected in accordance

with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are

applicable.

45 CFR Part 160, Subpart C—Compliance and Investigations

This subpart applies to actions by the Secretary, covered entities, business associates, and others with

respect to ascertaining the compliance by covered entities and business associates with, and the

enforcement of, the applicable provisions of this part 160 and parts 162 and 164 of this subchapter.

§160.310 Responsibilities of covered entities and business associates.

(a) Provide records and compliance reports. A covered entity or business associate must keep such

records and submit such compliance reports, in such time and manner and containing such information,

as the Secretary may determine to be necessary to enable the Secretary to ascertain whether the

covered entity or business associate has complied or is complying with the applicable administrative

simplification provisions.

(b) Cooperate with complaint investigations and compliance reviews. A covered entity or business

associate must cooperate with the Secretary, if the Secretary undertakes an investigation or compliance

review of the policies, procedures, or practices of the covered entity or business associate to determine

whether it is complying with the applicable administrative simplification provisions.

(c) Permit access to information.

(1) A covered entity or business associate must permit access by the Secretary during normal business

hours to its facilities, books, records, accounts, and other sources of information, including protected

health information, that are pertinent to ascertaining compliance with the applicable administrative

simplification provisions. If the Secretary determines that exigent circumstances exist, such as when

documents may be hidden or destroyed, a covered entity or business associate must permit access by

the Secretary at any time and without notice.

(2) If any information required of a covered entity or business associate under this section is in the

exclusive possession of any other agency, institution, or person and the other agency, institution, or

person fails or refuses to furnish the information, the covered entity or business associate must so certify

and set forth what efforts it has made to obtain the information.

(3) Protected health information obtained by the Secretary in connection with an investigation or

compliance review under this subpart will not be disclosed by the Secretary, except if necessary for

ascertaining or enforcing compliance with the applicable administrative simplification provisions, if

otherwise required by law, or if permitted under 5 U.S.C. 552a(b)(7).

§160.316 Refraining from intimidation or retaliation.

A covered entity or business associate may not threaten, intimidate, coerce, harass, discriminate against,

or take any other retaliatory action against any individual or other person for—

(a) Filing of a complaint under §160.306;

(b) Testifying, assisting, or participating in an investigation, compliance review, proceeding, or hearing

under this part; or

(c) Opposing any act or practice made unlawful by this subchapter, provided the individual or person has

a good faith belief that the practice opposed is unlawful, and the manner of opposition is reasonable and

142 Appendix

does not involve a disclosure of protected health information in violation of subpart E of part 164 of this

subchapter.


BHO Agreement Section(s) 10.9.3.5, 6.12.1.8



accordance with the privacy requirements of HIPAA (45 CFR 160).

The BHO monitors for compliance to HIPAA regulations and takes action to correct any

deficiencies.

The BHO has a policy and procedure to provide its own records and compliance reports, as well

as those of its covered entities or business associates, indicating all parties will comply with

applicable HIPAA administrative simplification provisions.

The BHO has a policy and procedure to ensure a covered entity or business associate may not

threaten, intimidate, coerce, harass, discriminate against, or take any other retaliatory action

against any individual or other person for filing a complaint with the State regarding HIPAA

compliance.

The BHO has a policy and procedure in place ensuring the BHO and its contracted entities

cooperate with HIPAA complaint investigations and compliance reviews.

42 U.S.C. §290dd–2 Confidentiality of records

(a) Requirement

Records of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in

connection with the performance of any program or activity relating to substance abuse education,

prevention, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or

indirectly assisted by any department or agency of the United States shall, except as provided in

subsection (e) of this section, be confidential and be disclosed only for the purposes and under the

circumstances expressly authorized under subsection (b) of this section.

(b) Permitted disclosure

(1) Consent

The content of any record referred to in subsection (a) of this section may be disclosed in accordance

with the prior written consent of the patient with respect to whom such record is maintained, but only to

such extent, under such circumstances, and for such purposes as may be allowed under regulations

prescribed pursuant to subsection (g) of this section.

(2) Method for disclosure

Whether or not the patient, with respect to whom any given record referred to in subsection (a) of this

section is maintained, gives his written consent, the content of such record may be disclosed as follows:

(A) To medical personnel to the extent necessary to meet a bona fide medical emergency.

(B) To qualified personnel for the purpose of conducting scientific research, management audits,

financial audits, or program evaluation, but such personnel may not identify, directly or indirectly, any

individual patient in any report of such research, audit, or evaluation, or otherwise disclose patient

identities in any manner.

(C) If authorized by an appropriate order of a court of competent jurisdiction granted after application

showing good cause therefor. In assessing good cause the court shall weigh the public interest and the

need for disclosure against the injury to the patient, to the physician-patient relationship, and to the

treatment services. Upon the granting of such order, the court, in determining the extent to which any

143 Appendix

disclosure of all or any part of any record is necessary, shall impose appropriate safeguards against



BHO Agreement Section(s) 3.4.1, 3.4.2



enrollees ensuring confidentiality and appropriate disclosure only with the enrollee’s consent.


enrollees identifying the purposes and circumstances of disclosure affecting the enrollee

regardless of consent.

CFR Part 2—Confidentiality of Alcohol and Drug Abuse Patient Records

§2.12 Applicability.

(a) General. (1) Restrictions on disclosure. The restrictions on disclosure in these regulations apply to any

information, whether or not recorded, which:

(i) Would identify a patient as having or having had a substance use disorder directly, by reference to

other publicly available information, or through verification of such an identification by another person;

and

(ii) Is drug abuse information obtained by a federally assisted drug abuse program after March 20, 1972

(part 2 program) or is alcohol abuse information obtained by a federally assisted alcohol abuse program

after May 13, 1974 (part 2 program);or if obtained before the pertinent date, is maintained by a part 2

program after that date as part of an ongoing treatment episode which extends past that date; for the

purpose of treating a substance use disorder, making a diagnosis for that treatment, or making a referral

for that treatment.

2) Restriction on use. The restriction on use of information to initiate or substantiate any criminal charges

against a patient or to conduct any criminal investigation of a patient (42 U.S.C. 290dd–2(c)), applies to

any information, whether or not recorded, which is drug abuse information obtained by a federally

assisted drug abuse program after March 20, 1972 (part 2 program), or is alcohol abuse information

obtained by a federally assisted alcohol abuse program after May 13, 1974 (part 2 program); or if

obtained before the pertinent date, is maintained by a part 2 program after that date as part of an ongoing

treatment episode which extends past that date; for the purpose of treating substance use disorder,

making a diagnosis for the treatment, or making a referral for the treatment.

(b) Federal assistance. A program is considered to be federally assisted if:

(1) It is conducted in whole or in part, whether directly or by contract or otherwise by any department or

agency of the United States (but see paragraphs (c)(1) and (c)(2) of this section relating to the Veterans'

Administration and the Armed Forces);

(2) It is being carried out under a license, certification, registration, or other authorization granted by any

department or agency of the United States including but not limited to:

(i) Participating provider in the Medicare program;

(ii) Authorization to conduct maintenance treatment or withdrawal management; or

(iii) Registration to dispense a substance under the Controlled Substances Act to the extent the controlled

substance is used in the treatment of substance use disorders;

(3) It is supported by funds provided by any department or agency of the United States by being:

(i) A recipient of federal financial assistance in any form, including financial assistance which does not

directly pay for the substance use disorder diagnosis, treatment, or referral activities; or

144 Appendix

(ii) Conducted by a State or local government unit which, through general or special revenue sharing or

other forms of assistance, receives federal funds which could be (but are not necessarily) spent for the

substance use disorder program.

(c) Exceptions.

(3) Communication within a part 2 program or between a part 2 program and an entity having direct

administrative control over that part 2 program. The restrictions on disclosure in the regulations in this

part do not apply to communications of information between or among personnel having a need for the

information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral

for treatment of patients with substance use disorders if the communications are

(i) Within a part 2 program or

(ii) Between a part 2 program and an entity that has direct administrative control over the program.

(4) Qualified Service Organizations. The restrictions on disclosure in these regulations do not apply to

communications between a part 2 program and a qualified service organization of information needed by

the organization to provide services to the program.

(5) Crimes on part 2 program premises or against part 2 program personnel. The restrictions on

disclosure and use in these regulations do not apply to communications from part 2 program personnel to

law enforcement agencies or officials which—

(i) Are directly related to a patient's commission of a crime on the premises of the part 2 program or

against part 2 program personnel or to a threat to commit such a crime; and

(ii) Are limited to the circumstances of the incident, including the patient status of the individual

committing or threatening to commit the crime, that individual's name and address, and that individual's

last known whereabouts.

§2.16 Security for written records.

(a) The part 2 program or other lawful holder of patient identifying information must have in place formal

policies and procedures to reasonably

protect against unauthorized uses and disclosures of patient identifying information and to protect against

reasonably anticipated threats or

hazards to the security of patient identifying information. These formal policies and procedures must

address: (1) Paper records, including:

(i) Transferring and removing such records;

(ii) Destroying such records, including sanitizing the hard copy media associated with the paper printouts,

to render the patient identifying information non-retrievable;

(iii) Maintaining such records in a secure room, locked file cabinet, safe, or other similar container, or

storage facility when not in use;

(iv) Using and accessing workstations, secure rooms, locked file cabinets, safes, or other similar

containers, and storage facilities that use or store such information; and

(v) Rendering patient identifying information non-identifiable in a manner that creates a very low risk of re-

identification (e.g., removing direct identifiers).

(2) Electronic records, including:

(i) Creating, receiving, maintaining, and transmitting such records;

(ii) Destroying such records, including sanitizing the electronic media on which such records are stored, to

render the patient identifying information nonretrievable;

(iii) Using and accessing electronic records or other electronic media containing patient identifying

information; and

(iv) Rendering the patient identifying information non-identifiable in a manner that creates a very low risk

of re-identification (e.g., removing direct identifiers).

§2.19 Disposition of records by discontinued programs.

145 Appendix

(a) General. If a part 2 program discontinues operations or is taken over or acquired by another program,

it must remove patient identifying information from its records or destroy the records, including sanitizing

any associated hard copy or electronic media, to render the

patient identifying information nonretrievable in a manner consistent with the policies and procedures

established under § 2.16, unless:

(1) The patient who is the subject of the records gives written consent (meeting the requirements of

§2.31) to a transfer of the records to the acquiring program or to any other program designated in the

consent (the manner of obtaining this consent must minimize the likelihood of a disclosure of patient

identifying information to a third party); or

(2) There is a legal requirement that the records be kept for a period specified by law which does not

expire until after the discontinuation or acquisition of the part 2 program.

(b) Special procedure where retention period required by law. If paragraph (a)(2) of this section applies,:

(1) Records, which are paper, must be

(i) sealed in envelopes or other containers labeled as follows: “Records of [insert name of program]

required to be maintained under [insert citation to statute, regulation, court order or other legal authority

requiring that records be kept] until a date not later than [insert appropriate date]”;

(A) All hard copy media from which

the paper records were produced, such as printer and facsimile ribbons, drums, etc., must be sanitized to

render the data non-retrievable; and

(B) [Reserved]

(ii) Held under the restrictions of the regulations in this part by a responsible person who must, as soon as

practicable after the end of the required retention period specified on the label, destroy the records and

sanitize any associated hard copy media to render the patient identifying information non-retrievable in a

manner consistent with the discontinued program’s or acquiring program’s policies and procedures

established under § 2.16.

§2.22 Notice to patients of federal confidentiality requirements.

(a) Notice required. At the time of admission to a part 2 program or, in the case that a patient does not

have capacity upon admission to understand his or her medical status, as soon threreafter as the patient

attains such capacity, each part 2 program shall:

(1) Communicate to the patient that federal law and regulations protect the confidentiality of substance

use disorder patient records; and

(2) Give to the patient a summary in writing of the federal law and regulations.

(b) Required elements of written summary. The written summary of the federal law and regulations must

include:

(1) A general description of the limited circumstances under which a part 2 program may acknowledge

that an individual is present or disclose outside the part 2 program information identifying a patient as

having or having had a substance use disorder;

(2) A statement that violation of the federal law and regulations by a part 2 program is a crime and that

suspected violations may be reported to appropriate authorities consisted with §2.4, along with contact

information .

(3) A statement that information related to a patient's commission of a crime on the premises of the part 2

program or against personnel of the part 2 program is not protected.

(4) A statement that reports of suspected child abuse and neglect made under state law to appropriate

state or local authorities are not protected; and

(5) A citation to the federal law and regulations.

(c) Program options. The part 2 program must devise a notice to comply with the requirement to provide

the patient with a summary in writing of the

146 Appendix

federal law and regulations. In this written summary, the part 2 program also may include information

concerning state law and any of the part

2 program’s policies that are not inconsistent with state and federal law on the subject of confidentiality of

substance use disorder patient records.

§2.23 Patient access and restrictions on use.

(a) Patient access not prohibited. These regulations do not prohibit a part 2 program from giving a patient

access to their own records, including the opportunity to inspect and copy any records that the part 2

program maintains about the patient. The part 2 program is not required to obtain a patient's written

consent or other authorization under these regulations in this part in order to provide such access to the

patient.

(b) Restriction on use of information. Information obtained by patient access to his or her patient record is

subject to the restriction on use of his information to initiate or substantiate any criminal charges against

the patient or to conduct any criminal investigation of the patient as provided for under §2.12(d)(1).


BHO Agreement Section(s) 3.4.1, 3.4.2



accordance with the privacy requirements detailed in 42 CFR Part 2.

The BHO has a policy and procedure to ensure that when coordinating care for enrollees, the

BHO and its business associates, covered entities, and contracted providers follow restrictions on

disclosure of enrollee information, security for written records, and disposition of records for

discontinued programs.

The BHO has a policy and procedure to ensure the confidentiality of enrollee drug and alcohol

records, including when disclosure will be granted, patient access, and restrictions on use of

information.

The BHO has a process in place to monitor its BHAs for care coordination and all other

healthcare services furnished to enrollees to make certain policies regarding confidentiality of

enrollee drug and alcohol records, as well as disclosure, enrollee access, and restrictions on use

of information are followed.

The BHO notifies enrollees of the circumstances in which disclosure is permitted without the

enrollee’s consent.

42 CFR Part 2—Confidentiality of Alcohol and Drug Abuse Patient Records

§2.53 Audit and evaluation activities.

(a) Records not copied or removed. If patient records are not downloaded, copied or removed from the

part 2 program premises or forwarded electronically to another electronic system or device, patient

identifying information, as defined in § 2.11, may be disclosed in the course of a review of records on the

part 2 program premises to any individual or entity who agrees in writing to comply with the limitations on

re-disclosure and use in paragraph (d) of this section and who:

(1) Performs the audit or evaluation activity on behalf of:

(i) Any federal, state, or local governmental agency which provides financial assistance to the part 2

program or is authorized by law to regulate its activities; or

(ii) Any individual or entity who provides financial assistance to the part 2 program, which is a third party

payer covering patients in the part 2 program, or which is a quality improvement organization performing

a utilization or quality control review; or

147 Appendix

(2) Is determined by the part 2 program to be qualified to conduct the audit or evaluation of the part 2

program.

(b) Copying, removing, downloading, or forwarding patient records. Records containing patient identifying

information may be copied or removed from part 2 program premises by any individual or entity who:

(1) Agrees in writing to:

(i) Maintain and destroy the patient identifying information in a manner consistent with the policies and

procedres established under §2.16;

(ii) Retain records in compliance with applicable federal, state, and local record retention laws; and (iii)

Comply with the limitations on disclosure and use in paragraph (d) of this section; and

(2) Performs the audit or evaluation activity on behalf of:

(i) Any federal, state, or local governmental agency which provides financial assistance to the part 2

program or is authorized by law to regulate its activities; or

(ii) Any individual or entity who provides financial assistance to the part 2 program, which is a third part

payer covering patients in the part 2 program, or which is a quality improvement organization performing

a utilization or quality control review.

(c) Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or related audit or evaluation. (2) A

Medicare, Medicaid, or CHIP audit or evaluation under this section includes a civil or administrative

investigation of a part 2 program by any federal, state, or local government agency with oversight

responsibilities for Medicare, Medicaid, or CHIP and includes administrative enforcement, against the part

2 program by the government agency, of any remedy authorized by law to be imposed as a result of the

findings of the investigation.

(d) Limitations on disclosure and use. Except as provided in paragraph (c) of this section, patient

identifying information disclosed under this section may be disclosed only back to the program from which

it was obtained and used only to carry out an audit or evaluation purpose or to investigate or prosecute

criminal or other activities, as authorized by a court order entered under §2.66 of these regulations.


BHO Program Agreement Sections: 3.4.1


The BHO has a procedure and policy in place that describe the auditing and evaluation of SUD

treatment records in accordance with §2.53.

The BHO has a process in place to ensure that if enrollee records are copied or removed from a

BHA during an audit, the confidentiality of PHI is maintained in accordance with the security

requirements discussed in 42 CFR.

The BHO has a process in place to make sure all PHI removed from the BHAs during an audit is

destroyed upon completion of the audit.

§431.300 Basis and purpose.

(a) Section 1902(a)(7) of the Act requires that a State plan must provide safeguards that restrict the use

or disclosure of information concerning applicants and beneficiaries to purposes directly connected with

the administration of the plan. This subpart specifies State plan requirements, the types of information to

be safeguarded, the conditions for release of safeguarded information, and restrictions on the distribution

of other information.

(b) For purposes of this subpart, information concerning an applicant or beneficiary includes information

on a non-applicant, as defined in §435.4 of this subchapter.

148 Appendix

(c) Section 1137 of the Act, which requires agencies to exchange information to verify the income and

eligibility of applicants and beneficiaries (see §435.940 through §435.965 of this subchapter), requires

State agencies to have adequate safeguards to assure that—

(1) Information exchanged by the State agencies is made available only to the extent necessary to assist

in the valid administrative needs of the program receiving the information, and information received under

section 6103(l)(7) of the Internal Revenue Code is exchanged only with agencies authorized to receive

that information under that section of the Code; and

(2) The information is adequately stored and processed so that it is protected against unauthorized

disclosure for other purposes.

§431.301 State plan requirements.

A State plan must provide, under a State statute that imposes legal sanctions, safeguards meeting the

requirements of this subpart that restrict the use or disclosure of information concerning applicants and

beneficiaries to purposes directly connected with the administration of the plan.

§431.302 Purposes directly related to State plan administration.

Purposes directly related to plan administration include—

(a) Establishing eligibility;

(b) Determining the amount of medical assistance;

(c) Providing services for beneficiaries; and

(d) Conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the

administration of the plan.

§431.307 Distribution of information materials.

(a) All materials distributed to applicants, beneficiaries, or medical providers must—

(1) Directly relate to the administration of the Medicaid program.


BHO Program Agreement Sections: 3.4.1



accordance with the privacy requirements in §§431.300, 431.301, and 431.302.

The BHO has a policy and procedure in place to ensure information exchanged by the BHO and

its BHAs is made available only to the extent necessary to assist in the valid administrative needs

of the program receiving the information and is adequately stored and protected against


The BHO has a mechanism in place to monitor that distribution of information directly relates to

the administration of the State plan.


(c) Additional services for enrollees with special health care needs or who need LTSS—(1) Identification.

The State must implement mechanisms to identify persons with special health care needs to MCOs,

PIHPs and PAHPs, as those persons are defined by the State. These identification mechanisms—

(i) Must be specified in the State's quality strategy under §438.340.

(ii) May use State staff, the State's enrollment broker, or the State's MCOs, PIHPs and PAHPs.

(2) Assessment. Each MCO, PIHP, and PAHP must implement mechanisms to comprehensively assess

each Medicaid enrollee identified by the State (through the mechanism specified in paragraph (c)(1) of

this section) and identified to the MCO, PIHP, and PAHP by the State as having special health care

needs to identify any ongoing special conditions of the enrollee that require a course of treatment or

149 Appendix

regular care monitoring. The assessment mechanisms must use appropriate providers or individuals

meeting coordination requirements of the State or the MCO, PIHP, or PAHP as appropriate.


WAC 388-865-0420

BHO Agreement Section(s)12.1.6, 12.2, 12.3


The BHO has a policy and procedure for assessing each enrollee in order to identify any ongoing

special conditions that may require a special course of treatment or regular care monitoring.

The BHO has a method for identifying enrollees with special healthcare needs. Special

healthcare needs include any physical, developmental, mental, sensory, behavioral, cognitive, or

emotional impairment or limiting condition that requires medical management, healthcare

intervention and/or use of specialized services or programs. The condition may be congenital or

developmental, or acquired through disease, trauma, or environmental cause and may impose

limitations in performing daily self-maintenance activities or substantial limitations in a major life

activity.

The BHO has a process in place to monitor compliance with this requirement.

The BHO has in effect mechanisms to detect both underutilization and overutilization of services,

and to assess the quality and appropriateness of care furnished to enrollees with special

healthcare needs.


(3) Treatment/service plans. MCOs, PIHPs, or PAHPs must produce a treatment or service plan meeting

the criteria in paragraphs (c)(3)(i) through (v) of this section for enrollees who have special healthcare

needs and, if the State requires, must produce a treatment or service plan meeting the criteria in

paragraphs (c)(3)(iii) through (v) of this section for enrollees with special health care needs that are

determined through assessment to need a course of treatment or regular care monitoring. The treatment

or service plan must be:

(i) Developed by an individual meeting special healthcare service coordination requirements with enrollee

participation, and in consultation with any providers caring for the enrollee;

(iii) Approved by the MCO, PIHP, or PAHP in a timely manner, if this approval is required by the MCO,

PIHP, or PAHP;

(iv) In accordance with any applicable State quality assurance and utilization review standards; and

(v) Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the

enrollee's circumstances or needs change significantly, or at the request of the enrollee per

§441.301(c)(3) of this chapter.


BHO Agreement Section(s) 10.9.3.4, 10.9.3.5, 16.4, 3.6.19


The BHO ensures that treatment plans for enrollees with special healthcare needs are developed

with the enrollee’s participation, and in consultation with any specialists caring for the enrollee.

The enrollee’s treatment plan incorporates the enrollee’s special healthcare needs.


150 Appendix

(4) Direct access to specialists. For enrollees with special health care needs determined through an

assessment by appropriate health care professionals (consistent with §438.208(c)(2)) to need a course of

treatment or regular care monitoring, each MCO, PIHP, and PAHP must have a mechanism in place to

allow enrollees to directly access a specialist (for example, through a standing referral or an approved

number of visits) as appropriate for the enrollee's condition and identified needs.


WAC 388-865-0430

BHO Agreement Section(s) 10.9


The BHO has policies and procedures regarding direct access to specialists for enrollees with

special healthcare needs.

The BHO monitors the availability of direct access to specialists.

Coverage and Authorization of Services §438.210 Coverage and authorization of services.

(a) Coverage. Each contract between a State and an MCO, PIHP, or PAHP must do the following:

(1) Identify, define, and specify the amount, duration, and scope of each service that the MCO, PIHP, or

PAHP is required to offer.

(2) Require that the services identified in paragraph (a)(1) of this section be furnished in an amount,

duration, and scope that is no less than the amount, duration, and scope for the same services furnished

to beneficiaries under FFS Medicaid, as set forth in §440.230 of this chapter, and for enrollees under the

age of 21, as set forth in subpart B of part 440 of this chapter.

(3) Provide that the MCO, PIHP, or PAHP—

(i) Must ensure that the services are sufficient in amount, duration, or scope to reasonably achieve the

purpose for which the services are furnished.

(ii) May not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because

of diagnosis, type of illness, or condition of the beneficiary.

(4) Permit an MCO, PIHP, or PAHP to place appropriate limits on a service—

(i) On the basis of criteria applied under the State plan, such as medical necessity; or

(ii) For the purpose of utilization control, provided that—

(A)The services furnished can reasonably achieve their purpose, as required in paragraph (a)(3)(i) of this

section;

(B) The services supporting individuals with ongoing or chronic conditions are authorized in a manner that

reflects the enrollee's ongoing need for such services and supports;

(5) Specify what constitutes “medically necessary services” in a manner that—

(i) Is no more restrictive than that used in the State Medicaid program, including quantitative and non-

quantitative treatment limits, as indicated in State statutes and regulations, the State Plan, and other

State policy and procedures; and

(ii) Addresses the extent to which the MCO, PIHP, or PAHP is responsible for covering services that

address:

(A) The prevention, diagnosis, and treatment of an enrollee's disease, condition, and/or disorder that

results in health impairments and/or disability.

(B) The ability for an enrollee to achieve age-appropriate growth and development.

(C) The ability for an enrollee to attain, maintain, or regain functional capacity.


151 Appendix

WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 6


The BHO monitors to ensure that services are provided in an amount, duration, and scope

sufficient to achieve the purpose for which they are provided.

The BHO does not arbitrarily deny or reduce the amount, duration, or scope of a required service

solely because of diagnosis, type of illness, or condition of the beneficiary.

The BHO applies the State’s standard for medical necessity when monitoring provided services

and making authorization decisions.

§438.210 Coverage and authorization of services.

(b) Authorization of services. For the processing of requests for initial and continuing authorizations of

services, each contract must require—

(1) That the MCO, PIHP, or PAHP and its subcontractors have in place, and follow, written policies and

procedures.

(2) That the MCO, PIHP, or PAHP—

(i) Have in effect mechanisms to ensure consistent application of review criteria for authorization

decisions.

(ii) Consult with the requesting provider when appropriate.

(3) That any decision to deny a service authorization request or to authorize a service in an amount,

duration, or scope that is less than requested, be made by an individual who has appropriate expertise in

addressing the enrollee's medical, behavioral health, or long-term services and supports needs.


WAC 388-865, 388-877, 388-777A, 388-877B



The BHO has documented policies and procedures for the consistent application of review criteria

pertaining to the initial and continuing authorization of services.

The BHO consults with the requesting BHA when appropriate.

The BHO has a process to ensure that any decision to deny a service authorization request or to

authorize a service in an amount, duration, or scope that is less than requested is made by a

mental health or chemical dependency professional who has appropriate clinical expertise in

treating the enrollee's condition or disease.

In the event of an inpatient stay, only a psychiatrist or clinical psychologist can issue a denial for

inpatient psychiatric services.


(c) Notice of adverse benefit determination. Each contract must provide for the MCO, PIHP, or PAHP to

notify the requesting provider, and give the enrollee written notice of any decision by the MCO, PIHP, or

PAHP to deny a service authorization request, or to authorize a service in an amount, duration, or scope

that is less than requested. For MCOs, PIHPs, and PAHPs, the enrollee's notice must meet the

requirements of §438.404.

§438.404 Timely and adequate notice of adverse benefit determination.

(a) Notice. The MCO, PIHP, or PAHP must give enrollees timely and adequate notice of an adverse

benefit determination in writing consistent with the requirements below and in §438.10.

152 Appendix

(b) Content of notice. The notice must explain the following:

(1) The adverse benefit determination the MCO, PIHP, or PAHP has made or intends to make.

(2) The reasons for the adverse benefit determination, including the right of the enrollee to be provided

upon request and free of charge, reasonable access to and copies of all documents, records, and other

information relevant to the enrollee's adverse benefit determination. Such information includes medical

necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits.

(3) The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit

determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal

described at §438.402(b) and the right to request a State fair hearing consistent with §438.402(c).

(4) The procedures for exercising the rights specified in this paragraph (b).

(5) The circumstances under which an appeal process can be expedited and how to request it.

(6) The enrollee's right to have benefits continue pending resolution of the appeal, how to request that

benefits be continued, and the circumstances, consistent with state policy, under which the enrollee may

be required to pay the costs of these services.

(c) Timing of notice. The MCO, PIHP, or PAHP must mail the notice within the following timeframes:

(1) For termination, suspension, or reduction of previously authorized Medicaid-covered services, within

the timeframes specified in §§431.211, 431.213, and 431.214 of this chapter.

(2) For denial of payment, at the time of any action affecting the claim.

(3) For standard service authorization decisions that deny or limit services, within the timeframe specified

in §438.210(d)(1).

(4) If the MCO, PIHP, or PAHP meets the criteria set forth for extending the timeframe for standard

service authorization decisions consistent with §438.210(d)(1)(ii), it must—

(i) Give the enrollee written notice of the reason for the decision to extend the timeframe and inform the

enrollee of the right to file a grievance if he or she disagrees with that decision; and

(ii) Issue and carry out its determination as expeditiously as the enrollee's health condition requires and

no later than the date the extension expires.

(5) For service authorization decisions not reached within the timeframes specified in §438.210(d) (which

constitutes a denial and is thus an adverse benefit determination), on the date that the timeframes expire.

(6) For expedited service authorization decisions, within the timeframes specified in §438.210(d)(2).


WAC 388-865, 388-877, 388-777A, 388-877B



The BHO has a documented policy and procedure to notify the requesting BHA and the enrollee

in writing of any decision by the BHO to deny an initial or continuing service authorization request,

or to authorize a service in an amount, duration, or scope that is less than requested.

The BHO ensures the notice meets the requirements of §438.404.


(d) Timeframe for decisions. Each MCO, PIHP, or PAHP contract must provide for the following decisions

and notices:

(1) Standard authorization decisions. For standard authorization decisions, provide notice as

expeditiously as the enrollee's health condition requires and within State-established timeframes that may

not exceed 14 calendar days following receipt of the request for service, with a possible extension of up

to 14 additional calendar days, if—

(i) The enrollee, or the provider, requests extension; or

153 Appendix

(ii) The MCO, PIHP, or PAHP justifies (to the State agency upon request) a need for additional

information and how the extension is in the enrollee's interest.

(2) Expedited authorization decisions. (i) For cases in which a provider indicates, or the MCO, PIHP, or

PAHP determines, that following the standard timeframe could seriously jeopardize the enrollee's life or

health or ability to attain, maintain, or regain maximum function, the MCO, PIHP, or PAHP must make an

expedited authorization decision and provide notice as expeditiously as the enrollee's health condition

requires and no later than 72 hours after receipt of the request for service.

(ii) The MCO, PIHP, or PAHP may extend the 72 hour time period by up to 14 calendar days if the

enrollee requests an extension, or if the MCO, PIHP, or PAHP justifies (to the State agency upon request)

a need for additional information and how the extension is in the enrollee's interest.


WAC 388-865, 388-877, 388-777A, 388-877B



The BHO has a documented policy and procedure for standard and expedited authorization

decisions. The BHO has a process for tracking standard and expedited authorization decisions.

The BHO has mechanisms in place to ensure compliance with standard and expedited

authorization timeframes.


(e) Compensation for utilization management activities. Each contract between a State and MCO, PIHP,

or PAHP must provide that, consistent with §§438.3(i), and 422.208 of this chapter, compensation to

individuals or entities that conduct utilization management activities is not structured so as to provide

incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any

enrollee.


WAC 388-865, 388-877, 388-777A, 388-877B



The BHO has a documented policy and procedure specifying that compensation to individuals or

entities that conduct utilization management activities is not structured so as to provide incentives

for the individual or entity to deny, limit, or discontinue medically necessary services to any

enrollee.

The BHO has mechanisms in place to ensure BHAs and/or utilization management contractors

do not provide staff with incentives to deny, limit, or discontinue medically necessary services.

§438.114 Emergency and post-stabilization services.

(a) Definitions. As used in this section—

Emergency medical condition means a medical condition manifesting itself by acute symptoms of

sufficient severity (including severe pain) that a prudent layperson, who possesses an average

knowledge of health and medicine, could reasonably expect the absence of immediate medical attention

to result in the following:

(1) Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn

child) in serious jeopardy.

154 Appendix

(2) Serious impairment to bodily functions.

(3) Serious dysfunction of any bodily organ or part.

Emergency services means covered inpatient and outpatient services that are as follows:

(1) Furnished by a provider that is qualified to furnish these services under this Title.

(2) Needed to evaluate or stabilize an emergency medical condition.

Post-stabilization care services means covered services, related to an emergency medical condition that

are provided after an enrollee is stabilized in order to maintain the stabilized condition, or, under the

circumstances described in paragraph (e) of this section, to improve or resolve the enrollee's condition.

(b) Coverage and payment: General rule. The following entities are responsible for coverage and

payment of emergency services and post-stabilization care services.

(1) The MCO, PIHP, or PAHP.

(2) The State, for managed care programs that contract with PCCMs or PCCM entities.

(c) Coverage and payment: Emergency services. (1) The entities identified in paragraph (b) of this

section—

(i) Must cover and pay for emergency services regardless of whether the provider that furnishes the

services has a contract with the MCO, PIHP, PAHP, or PCCM entity; and

(ii) May not deny payment for treatment obtained under either of the following circumstances:

(A) An enrollee had an emergency medical condition, including cases in which the absence of immediate

medical attention would not have had the outcomes specified in paragraphs (1), (2), and (3) of the

definition of emergency medical condition in paragraph (a) of this section.

(B) A representative of the MCO, PIHP, PAHP, or PCCM instructs the enrollee to seek emergency

services.

(2) A PCCM or PCCM entity must allow enrollees to obtain emergency services outside the primary care

case management system regardless of whether the case manager referred the enrollee to the provider

that furnishes the services.

(d) Additional rules for emergency services. (1) The entities specified in paragraph (b) of this section may

not—

(i) Limit what constitutes an emergency medical condition with reference to paragraph (a) of this section,

on the basis of lists of diagnoses or symptoms; and

(ii) Refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent

not notifying the enrollee's primary care provider, MCO, PIHP, PAHP or applicable State entity of the

enrollee's screening and treatment within 10 calendar days of presentation for emergency services.

(2) An enrollee who has an emergency medical condition may not be held liable for payment of

subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.

(3) The attending emergency physician, or the provider actually treating the enrollee, is responsible for

determining when the enrollee is sufficiently stabilized for transfer or discharge, and that determination is

binding on the entities identified in paragraph (b) of this section as responsible for coverage and payment.

(e) Coverage and payment: Poststabilization care services. Poststabilization care services are covered

and paid for in accordance with provisions set forth at §422.113(c) of this chapter. In applying those

provisions, reference to “MA organization” and “financially responsible” must be read as reference to the

entities responsible for Medicaid payment, as specified in paragraph (b) of this section, and payment

rules governed by Title XIX of the Act and the States

(f) Applicability to PIHPs and PAHPs. To the extent that services required to treat an emergency medical

condition fall within the scope of the services for which the PIHP or PAHP is responsible, the rules under

this section apply.


WAC 388-865, 388-877, 388-777A, 388-877B

BHO Agreement Section(s) 10.9, 15, 6.3

155 Appendix


The BHO has written policies and procedures pertaining to crisis, stabilization, and post-hospital

follow-up services.

The BHO pays for treatment of conditions defined in its policies as urgent or emergent conditions.

The BHO tracks and monitors to ensure that there is no payment denial for crisis services.

The BHO tracks and monitors use of crisis services for inappropriate or avoidable use related to

access to routine care.

Provider Selection §438.214 Provider selection.

(a) General rules. The State must ensure, through its contracts, that each MCO, PIHP, or PAHP

implements written policies and procedures for selection and retention of network providers and that

those policies and procedures, at a minimum, meet the requirements of this section.

(b) Credentialing and recredentialing requirements. (1) Each State must establish a uniform credentialing

and recredentialing policy that addresses acute, primary, behavioral, substance use disorders, as

appropriate, and requires each MCO, PIHP and PAHP to follow those policies.

(2) Each MCO, PIHP, and PAHP must follow a documented process for credentialing and recredentialing

of network providers.

(e) State requirements. Each MCO, PIHP, and PAHP must comply with any additional requirements

established by the State.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 5.8, 8, 10, 11


The BHO has a credentialing and re-credentialing policy and procedure for providers who have

signed contracts or participation agreements.

The BHO has a documented process for credentialing.

The BHO has a documented process for re-credentialing.

The BHO annually monitors the credentialing and re-credentialing process.

The BHO ensures the BHAs have credentialing and re-credentialing polices and processes in

place.

§438.214 Provider selection.

(c) Nondiscrimination. MCO, PIHP, and PAHP provider selection policies and procedures, consistent with

§438.12, must not discriminate against particular providers that serve high-risk populations or specialize

in conditions that require costly treatment.

§438.12 Provider discrimination prohibited.

(a) General rules. (1) An MCO, PIHP, or PAHP may not discriminate in the participation, reimbursement,

or indemnification of any provider who is acting within the scope of his or her license or certification under

applicable State law, solely on the basis of that license or certification. If an MCO, PIHP, or PAHP

declines to include individual or groups of providers in its provider network, it must give the affected

providers written notice of the reason for its decision.

(2) In all contracts with network providers, an MCO, PIHP, or PAHP must comply with the requirements

specified in §438.214.

156 Appendix

(b) Construction. Paragraph (a) of this section may not be construed to—

(1) Require the MCO, PIHP, or PAHP to contract with providers beyond the number necessary to meet

the needs of its enrollees;

(2) Preclude the MCO, PIHP, or PAHP from using different reimbursement amounts for different

specialties or for different practitioners in the same specialty; or

(3) Preclude the MCO, PIHP, or PAHP from establishing measures that are designed to maintain quality

of services and control costs and are consistent with its responsibilities to enrollees.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 3.8, 5


The BHO has provider selection policies and procedures, consistent with §438.12, that ensure

the BHO does not discriminate against particular providers that serve high-risk populations or

specialize in conditions that require costly treatment.

The BHO has policies and procedures in place that ensure the BHO does not discriminate in the

participation, reimbursement, or indemnification of any provider who is acting within the scope of

their license or certification, solely on the basis of that license or certification.

The BHO has a process for notifying individuals or groups of providers when they are not chosen

for participation in the network.

§438.214 Excluded providers.

(d) Excluded providers. MCOs, PIHP s, and PAHPs may not employ or contract with providers excluded

from participation in federal health care programs under either section 1128 or section 1128A of the Act.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has a policy and procedure to ensure the BHO does not employ or contract with

providers excluded from participation in federal healthcare programs.

The BHO can demonstrate the process and the documentation to determine whether individuals

or organizations are excluded providers.

The BHO ensures it is not employing or appointing on the governing board a person with

beneficial ownership of more than five percent of the BHO’s equity.

The BHO's provider contracts include the provision that providers do not knowingly have a

director, officer, partner, or other person excluded from participation in federal healthcare

programs with a beneficial ownership of more than five percent of the agency's equity.

Subcontractual Relationships and Delegation §438.230 Subcontractual relationships and delegation.

(a) Applicability. The requirements of this section apply to any contract or written arrangement that an

MCO, PIHP, PAHP, or PCCM entity has with any subcontractor.

(b) General rule. The State must ensure, through its contracts with MCOs, PIHPs, PAHPs, and PCCM

entities that—

157 Appendix

(1) Notwithstanding any relationship(s) that the MCO, PIHP, PAHP, or PCCM entity may have with any

subcontractor, the MCO, PIHP, PAHP, or PCCM entity maintains ultimate responsibility for adhering to

and otherwise fully complying with all terms and conditions of its contract with the State; and

(2) All contracts or written arrangements between the MCO, PIHP, PAHP, or PCCM entity and any

subcontractor must meet the requirements of paragraph (c) of this section.

(c) Each contract or written arrangement described in paragraph (b)(2) of this section must specify that:

(1) If any of the MCO's, PIHP's, PAHP's, or PCCM entity's activities or obligations under its contract with

the State are delegated to a subcontractor—

(i) The delegated activities or obligations, and related reporting responsibilities, are specified in the

contract or written agreement.

(ii) The subcontractor agrees to perform the delegated activities and reporting responsibilities specified in

compliance with the MCO's, PIHP's, PAHP's, or PCCM entity's contract obligations.

(iii) The contract or written arrangement must either provide for revocation of the delegation of activities or

obligations, or specify other remedies in instances where the State or the MCO, PIHP, PAHP, or PCCM

entity determine that the subcontractor has not performed satisfactorily.

(2) The subcontractor agrees to comply with all applicable Medicaid laws, regulations, including

applicable subregulatory guidance and contract provisions;

(3) The subcontractor agrees that—

(i) The State, CMS, the HHS Inspector General, the Comptroller General, or their designees have the

right to audit, evaluate, and inspect any books, records, contracts, computer or other electronic systems

of the subcontractor, or of the subcontractor's contractor, that pertain to any aspect of services and

activities performed, or determination of amounts payable under the MCO's, PIHP's, or PAHP's contract

with the State.

(ii) The subcontractor will make available, for purposes of an audit, evaluation, or inspection under

paragraph (c)(3)(i) of this section, its premises, physical facilities, equipment, books, records, contracts,

computer or other electronic systems relating to its Medicaid enrollees.

(iii) The right to audit under paragraph (c)(3)(i) of this section will exist through 10 years from the final date

of the contract period or from the date of completion of any audit, whichever is later.

(iv) If the State, CMS, or the HHS Inspector General determines that there is a reasonable possibility of

fraud or similar risk, the State, CMS, or the HHS Inspector General may inspect, evaluate, and audit the

subcontractor at any time.


WAC 388-865, 388-877, 388-777A, 388-877B



The BHO has policies and procedures for oversight and accountability for any functions and

responsibilities it delegates to its subcontractors/BHAs.

The BHO performs pre-delegation assessments of contracted BHAs before delegation is granted

on the subcontractor's ability to perform the activities to be delegated.

The BHO has written contracts/agreements that address the specifics of the activities that have

been delegated to the subcontractor/BHA.

The BHO monitors the subcontractor's performance on an ongoing basis and subjects it to formal

review according to a periodic schedule established by the State, consistent with industry

standards or State laws and regulations.

The BHO includes in the delegation contract/agreement that the BHO is responsible for

monitoring and reviewing the subcontractor's/BHA's performance on an ongoing basis and

158 Appendix

provides criteria for revoking delegation or imposing other sanctions if the subcontractor's

performance is inadequate.

The BHO initiates a corrective action if subcontractor/BHA performance does not meet industry

standards and/or requirements in the delegation or contract agreement.

The BHO follows up on any corrective action plan given to its subcontractor to ensure it has met

the criteria and, if the criteria is not met, imposes further corrective action, including revoking the

delegated activity.

The BHO requires the BHAs to follow the same CFR criteria for any services the BHAs delegate

to other entities.

The BHO monitors the BHAs’ delegated agreements with other entities.

Practice Guidelines §438.236 Practice guidelines.

(a) Basic rule. The State must ensure, through its contracts, that each MCO and, when applicable, each

PIHP and PAHP meets the requirements of this section.

(b) Adoption of practice guidelines. Each MCO and, when applicable, each PIHP and PAHP adopts

practice guidelines that meet the following requirements:

(1) Are based on valid and reliable clinical evidence or a consensus of providers in the particular field.

(2) Consider the needs of the MCO, PIHP, or PAHP's enrollees.

(3) Are adopted in consultation with contracting health care professionals.

(4) Are reviewed and updated periodically as appropriate.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has documented policies and procedures related to adoption of practice guidelines,

including consultation with contracting healthcare professionals.

The BHO’s guidelines are based on valid and reliable clinical evidence or a consensus of

healthcare professionals in the particular field.

The BHO has documentation of its enrollees’ needs and how the guidelines fit those needs.

The BHO has documentation that the guidelines are reviewed and updated yearly.

The BHO has a documented policy and procedure for how affiliated BHAs are consulted as

guidelines are adopted and re-evaluated.

§438.236 Practice guidelines.

(c) Dissemination of guidelines. Each MCO, PIHP and PAHP disseminates the guidelines to all affected

providers and, upon request, to enrollees and potential enrollees.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has a policy and procedure on how to disseminate practice guidelines to all providers

and, upon request, to enrollees and potential enrollees.

The BHO can demonstrate it has disseminated the practice guidelines to all BHAs and to

159 Appendix

enrollees upon request.

§438.236 Practice guidelines.

(d) Application of guidelines. Decisions for utilization management, enrollee education, coverage of

services and other areas to which the guidelines apply are consistent with the guidelines.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has documented policies and procedures as well as documented meeting minutes

demonstrating that decisions for utilization management, enrollee education, coverage of

services, and other areas to which the guidelines apply are consistent with the guidelines.

The BHO annually monitors the effective use of practice guidelines by the BHAs.

The BHO has documentation of the interface process between the QAPI program and the

practice guidelines adoption process.

Health Information Systems §438.242 Health information systems.

(a) General rule. The State must ensure, through its contracts that each MCO, PIHP, and PAHP

maintains a health information system that collects, analyzes, integrates, and reports data and can

achieve the objectives of this part. The systems must provide information on areas including, but not

limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of Medicaid

eligibility.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 11, section 13 (Behavioral Health Data Management) and 9.7 (Encounter

Data Validation).


The BHO has a health information system that collects, analyzes, integrates, and reports data on

utilization, dis-enrollments, requests to change providers, grievances, and appeals.

The BHO utilizes reports from health information data to make informed management decisions.

The BHO uses the information it has collected and analyzed to identify trends in areas including

but not limited to utilization, grievances and appeals, dis-enrollments, and requests to change

providers.

The BHO analyzes the health information data to identify services needed for enrollees.

Quality Assessment and Performance Improvement Program §438.330 Quality assessment and performance improvement program.

(a) General rules. (1) The State must require, through its contracts, that each MCO, PIHP, and PAHP

establish and implement an ongoing comprehensive quality assessment and performance improvement

program for the services it furnishes to its enrollees that includes the elements identified in paragraph (b)

of this section.

(2) After consulting with States and other stakeholders and providing public notice and opportunity to

comment, CMS may specify performance measures and PIPs, which must be included in the standard

160 Appendix

measures identified and PIPs required by the State in accordance with paragraphs (c) and (d) of this

section. A State may request an exemption from including the performance measures or PIPs established

under paragraph (a)(2) of this section, by submitting a written request to CMS explaining the basis for

such request.

(3) The State must require, through its contracts, that each PCCM entity described in §438.310(c)(2)

establish and implement an ongoing comprehensive quality assessment and performance improvement

program for the services it furnishes to its enrollees which incorporates, at a minimum, paragraphs (b)(2)

and (3) of this section and the performance measures identified by the State per paragraph (c) of this

section.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has an ongoing quality assessment and performance improvement program (QAPI) for

the services it furnishes to its enrollees.

The BHO has a written QAPI program.

The BHO has a QA and PI process to evaluate the QAPI program and updates its annual plan.



The BHO has a Quality Management Committee that meets regularly, reviews results of

performance data and reports to the governing board.

The BHO has effective mechanisms to assess the quality and appropriateness of care furnished

to enrollees.

The BHO conducts one clinical performance improvement project, one substance use disorder

performance improvement project, and one non-clinical performance improvement project each

year, one of which is a children-focused performance improvement project.

The BHO ensures its compliance with the State’s quality strategy plan.

§438.330 Quality assessment and performance improvement program.

(b) Basic elements of quality assessment and performance improvement programs. The comprehensive

quality assessment and performance improvement program described in paragraph (a) of this section

must include at least the following elements:

(1) Performance improvement projects in accordance with paragraph (d) of this section.

(2) Collection and submission of performance measurement data in accordance with paragraph (c) of this

section.

(3) Mechanisms to detect both underutilization and overutilization of services.

(4) Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special

health care needs, as defined by the State in the quality strategy under §438.340.


WAC 388-865, 388-877, 388-877A, 388-877B

BHO Agreement Section(s) 9.3, 9.81, 9.82




161 Appendix

The BHO reports performance data to the State every year.

The BHO has a documented policy and procedure regarding the detection of both underutilization

and overutilization of services in all its programs.

The BHO has consistent criteria for identifying underutilization and overutilization.

The BHO has processes for routine monitoring of underutilization and overutilization.

The BHO has processes for taking corrective action to address underutilization and

overutilization.


(c) Performance measurement. The State must—

(1)(i) Identify standard performance measures, including those performance measures that may be

specified by CMS under paragraph (a)(2) of this section, relating to the performance of MCOs, PIHPs,

and PAHPs;

(2) Require that each MCO, PIHP, and PAHP annually—

(i) Measure and report to the State on its performance, using the standard measures required by the

State in paragraph (c)(1) of this section;

(ii) Submit to the State data, specified by the State, which enables the State to calculate the MCO's,

PIHP's, or PAHP's performance using the standard measures identified by the State under paragraph

(c)(1) of this section; or

(iii) Perform a combination of the activities described in paragraphs (c)(2)(i) and (ii) of this section.


WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has a process in place to assess the standard performance measures.

The BHO measures and reports to the State on its performance, using the standard measures

required by the State.

The BHO has processes to submit data to DBHR, which enables the State to calculate the BHO’s

performance using standard measures.


(d) Performance improvement projects. (1) The State must require that MCOs, PIHPs, and PAHPs

conduct performance improvement projects, including any performance improvement projects required by

CMS in accordance with paragraph (a)(2) of this section, that focus on both clinical and nonclinical areas.

(2) Each performance improvement project must be designed to achieve significant improvement,

sustained over time, in health outcomes and enrollee satisfaction, and must include the following

elements:

(i) Measurement of performance using objective quality indicators.

(ii) Implementation of interventions to achieve improvement in the access to and quality of care.

(iii) Evaluation of the effectiveness of the interventions based on the performance measures in paragraph

(d)(2)(i) of this section.

(iv) Planning and initiation of activities for increasing or sustaining improvement.

(3) The State must require each MCO, PIHP, and PAHP to report the status and results of each project

conducted per paragraph (d)(1) of this section to the State as requested, but not less than once per year.


WAC 388-865, 388-877, 388-877A, 388-877B

162 Appendix



The BHO has a process in place to assess the quality and appropriateness of care furnished to

enrollees.

The BHO monitors and tracks the quality and appropriateness of care furnished to enrollees.

The BHO has processes for taking action when quality and appropriateness of care issues are

identified.


(e) Program review by the State. (1) The State must review, at least annually, the impact and

effectiveness of the quality assessment and performance improvement program of each MCO, PIHP,

PAHP, and PCCM entity described in §438.310(c)(2). The review must include—

(i) The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required

to report

(ii) The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement

projects

(2) The State may require that an MCO, PIHP, PAHP, or PCCM entity described in §438.310(c)(2)

develop a process to evaluate the impact and effectiveness of its own quality assessment and



WAC 388-865, 388-877, 388-877A, 388-877B



The BHO has a process in place to submit its QAPI program evaluation to the State at least annually.

The BHO monitors and tracks its required performance measures.

The BHO has processes to report outcomes and trended results of its performance improvement projects.

The BHO has a process in place to evaluate the impact and effectiveness of its own QAPI

program.

163 Appendix

Appendix F: Acronyms

ACA Affordable Care Act

ADA Americans with Disabilities Act

ANSI ASC American National Standards Institute, the Accredited Standards Committee

ASAM American Society of Addiction Medicine

BC/DR Business Continuity and Disaster Recovery

BCP Business Continuity Plan

BHA Behavioral Health Agency

BHDS Behavioral Health Data System

BHO Behavioral Health Organization

CANS Child and Adolescent Needs and Strengths

CAP Corrective Action Plan

CDP Chemical Dependency Professional

CFR Code of Federal Regulations

CMS Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology

DBHR Division of Behavioral Health and Recovery

DCFS Division of Children and Family Services

DSHS Department of Social and Health Services

DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

E&T Evaluation and Treatment

ED Emergency Department

EDI Electronic Data Interchange

EDV Encounter Data Validation

EHR Electronic Health Record

EQR External Quality Review

EQRO External Quality Review Organization

FFS Fee for Service

GIS Geographic Information Systems

HCA Health Care Authority

HHS Health & Human Services

HIPAA Health Insurance Portability and Accountability Act

ISCA Information System Capability Assessment

ISO/IEC International Organization for Standardization/International Electrotechnical Commission

ISO/IEEE International Standards Organization/Institute of Electrical and Electronics Engineers

ISP Individual Service Plan

IT Information Technology

LEIE List of Excluded Individuals and Entities

MCO Managed Care Organization

MMIS Medicaid Management Information System

NIST National Institute of Standards and Technology

PAHP Prepaid Ambulatory Health Plans

PCP Primary Care Provider

PDSA Plan-Do-Study-Act

PHI Protected Health Information

PII Personally Identifiable Information

PIHP Prepaid Inpatient Health Plan

164 Appendix

PIP Performance Improvement Project

QA/PI Quality Assurance and Performance Improvement

QAPI Quality Assessment and Performance Improvement

QRT Quality Review Team

RFT Residential Treatment Facility

RSN Regional Support Network

SERI Service Encounter Reporting Instructions

SUD Substance Use Disorder

WAC Washington Administrative Code

WISe Wraparound with Intensive Services

WSIPP Washington State Institute for Public Policy

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