Clinical Criteria
The clinical criteria used by ValueOptions to make admission, level of care and continuing treatment decisions reflect ValueOptions’ philosophy and clinical values. These criteria are assessed and revised at least annually by ValueOptions’ Corporate Executive Medical Management Committee (EMMC) and Clinical Advisory Committees.
Sources for the Kansas criteria is:
- The American Society of Addiction Medicine standards (ASAM);
ValueOptions has also adopted for use the ASAM PPC-2 criteria published by the American Society for Addiction Medicine (ASAM).
Treatment Guidelines
In addition to clinical criteria, ValueOptions has a set of Diagnoses-Based Treatment Guidelines. These guidelines are used in collaboration with providers to help guide appropriate and clinically effective care for a variety of complex psychiatric conditions. These guidelines represent standards of best practice for treating these complex conditions and can be referred to by Clinical Care Managers (CCM) and Peer Advisors (PA) during reviews. ValueOptions seeks input from providers, consultants, and other expert clinicians to develop some of the guidelines, but for the most part ValueOptions generally adopts guidelines existent in the professional literature such as those developed by the APA (e.g., Bipolar, Major Depression, Schizophrenia, Eating Disorder and ECT).
Access to Care/Referral Decision
ValueOptions’ care management system provides multiple channels of access to care for members. Ease of access to appropriate care is central to our philosophy and clinical values. A member or provider may access the care system through any of the following avenues:
- 24-hour toll-free emergency care/clinical referral line
- Direct certification of all levels of care through referral by a ValueOptions’ CCM
- In-person evaluations by network providers with assessment completed in the KCPC Web-based application
- Emergency services through freestanding psychiatric hospitals, medical hospitals with psychiatric units, emergency rooms or crisis response teams
Prior to initial determination of medical necessity, the CCM or customer service staff checks the member’s eligibility status and benefit plan. If eligibility information is not available, in non-urgent/emergent situations the CCM will complete the screening assessment and pend the certification awaiting eligibility verification.
CCMs will work with members who are in need of urgent/emergent care regardless of eligibility status.
If a member is no longer eligible for benefits, the CCM will refer the member to appropriate community supports and programs, such as local or state-funded agencies or facilities, sliding scale discounts for continuation in outpatient therapy, or explore benefit exchanges with the insurer/payer. This coordination is intended to appropriately transition the member to other care and guard against patient abandonment.
If a call is received from a member requesting care, the CCM conducts a brief screening to assess whether there is a need for urgent or emergent care. Wherever possible, potential AAPS funded members will be referred to a RADAC for AAPS screening and eligibility. ValueOptions’ staff makes referrals to appropriate network providers, taking into account member preferences such as geographic location, hours of service, cultural or language requirements, ethnicity, type of degree the provider holds and gender.
Review of Inpatient or Higher Levels of Care
All inpatient and alternative level of care programs (this does not include outpatient therapy rendered in a provider’s office or outpatient therapy in a clinic or hospital setting) will be subject to the review requirements described in this section. Prior to beginning treatment, the provider must contact ValueOptions:
- For notification
- To confirm benefits and eligibility
- To provide clinical information regarding the member’s condition and proposed treatment
- For authorizations or certifications
CCMs/Referral Line Clinicians are available 7 days a week, 24 hours a day, 365 days a year to provide assessment and referral and conduct certification review. Except for in cases where the service is classified as “On-Demand”, Precertification is the preferred type of review for higher levels of care; however, providers are expected to ensure the safety of members and may request certification of emergency care within 24 hours of an admission to an inpatient unit. Precertification review is conducted with the requesting provider or his/her delegate, and decisions are based on ASAM clinical criteria for the specified level of care. If a course of treatment is determined to be medically necessary, the certification will be for a specific period of time and level of care commensurate with the member’s clinical condition. If prior to the end of the initial or any subsequent certification, the provider proposes to continue treatment, he or she must call ValueOptions for a review and recertification of medical necessity.
The CCM conducts the continued stay review (CSR) with a focus on continued severity of symptoms, appropriateness and intensity of treatment plan, member progress and discharge planning. This is accomplished by reviewing the CSR summary in the KCPC and when indicated, in discussions with the provider or appropriate facility staff. The clinical information is documented and certified according to ASAM clinical criteria in the KCPC. Cases not meeting clinical criteria require Peer Advisor (PA) intervention via the peer review process. Any questionable or absent treatment plans, discharge plans or questions related to the quality and appropriateness of care being delivered are also referred to a Peer Advisor for review.
Clinical Review Process
Our partnership with providers is dependent upon a cooperative effort to review care prospectively. Providers must notify ValueOptions through the KCPC or by phone for Inpatient Services prior to admitting a member to any level of care with the exception of “On Demand Services” such as services to pregnant women or women with children and for social detoxification. Criteria for admission to “On Demand” Services will be established after admission through the submission of the KCPC to ValueOptions for review. In all cases, providers are encouraged to contact ValueOptions by phone, KCPC, or through Provider Connect prior to initiating any treatment to verify member eligibility and preauthorization requirements.
When a request for services is received, once it is established that the member is eligible for benefits under the identified plan, the CCM gathers the required clinical information, references the appropriate criteria set, and determines whether the requested care meets medical necessity criteria. The CCM may certify levels of care and treatment services that are specified as available under the specific benefit plan (e.g., acute inpatient, residential, partial hospitalization, intensive outpatient, or outpatient). Care is certified for a specific number of services/days for a specific time period. CCM’s have some flexibility in the certification limit, based on an individual member’s clinical needs and provider characteristics.
Kansas Authorization Timeframes:
Utilization Management Guidelines
Service |
Authorization Method |
Unit |
Initial Authorization timeframe |
Level IV |
Telephonic Review |
Day |
3 – 7 days |
Level III.2-D |
Review of |
Day |
5 – 7 days (This is an on demand service with the request submitted to VO with a minimum the first 3 dimensions of the KCPC completed) |
Level III.3/III.5 |
Review of KCPC followed by Telephonic Review |
Day |
7-14 days with CSR based on Medical Necessity up to 14 days |
Level III.1 |
Review of KCPC followed by Telephonic Review |
Day |
14 days with CSR based on Medical Necessity up to 30 days |
Level II.1 |
Review of KCPC |
Day |
Adults & Adolescents- 30 days authorized for a 10 week period to accommodate delayed start. CSR timeframes based on medical necessity. |
Level I |
Review of KCPC |
Unit |
Between 40 to 60 hours of treatment, depending on severity, over 16 weeks to accommodate delayed start. |
Other Services |
KCPC |
Unit |
40 units for every 12 weeks of treatment. |
Person Centered Case Management* |
KCPC |
|
40 units for every 12 weeks of treatment. |
Overnight Boarding rate for each child when child is present with Mother who is in level III services |
KCPC |
Day |
One day for each day in level 3 treatment services when the child is present with mother. |
Support Services * |
KCPC |
Unit |
40 units for every 12 weeks of treatment. |
*In regards to the "Other Services" section of the Utilization Management Guidelines, if you are requesting any of these services in addition to a main modality of care (i.e. Reintegration, Outpatient etc.) the service periods must match and therefore the units authorized may be adjusted to accommodate the primary modality of care.
As indicated above, ValueOptions’ policy is to prospectively review and approve all requests for services. We recognize that under some circumstances providers may deliver care before requesting a review by ValueOptions. When a provider requests a review for services that have already been delivered (retrospective review), ValueOptions will first determine whether such a retrospective review (e.g., emergency admission, members failure to indicate appropriate benefit coverage) is necessary and appropriate, and if so, may request needed medical records from the provider.
In cases where a retrospective review request is not justified, services may be reviewed and administratively denied. Administrative exceptions to this policy may be made for extenuating circumstances, determined on a case-by-case basis, or based on contractual requirements. If the admission meets the criteria for emergency admission, a medical necessity determination can be obtained retroactively within 24 hours of the admission.
Review Format
The medical necessity determination process is driven by the ASAM PPC-2R criteria contained in the KCPC system. The provider must submit the KCPC evaluation and service request to ValueOptions for the initial authorization and for all Continued Stay reviews. Upon receipt of the KCPC, a ValueOptions Care Manager will review the assessor’s submitted KCPC and any associated releases for medical necessity. When necessary the care manager will complete a telephonic review based on the KCPC information and summary submitted to ValueOptions. Transfers from Levels, Open Continued stay reviews, Continued stay reviews, and Initial Assessments will all be managed by ValueOptions with appropriate file transfers completed based on the submission of the necessary releases of information through the KCPC and Provider Connect.