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OMAP Responds to Questions of Children's Providers
May 27, 2001

The Office of Medical Assistance Programs (OMAP) has responded to letters written by the Associaiton on behalf of children's providers. The letters offer clarity on issues of increasing Art Therapy limits, deficiencies receieved by providers when requesting prior authorization for BHRS services, and the billing of BHRS services and partial hospitalization on the same day. The text of the letters is printed below for review. Questions can be directed to Lisa Lowrie at PCPA.

Commonwealth of Pennsylvania
Department of Public Welfare
Office of Medical Assistance Programs
PO Box 2675
Harrisburg, PA 17105-2675

May 21, 2001

Ms. Lisa M. Lowrie, LSW
Children's Policy Specialist
Pennsylvania Community Providers Association
2400 Park Drive
Harrisburg, Pennsylvania 17110-9303

Dear Ms. Lowrie:

Thank you for your letter dated April 19, 2001, recommending an increase in the current Medical Assistance (MA) Program Fee Schedule minimum hour limit for Art Therapy. As you stated in your letter, the Department of Public Welfare's (Department) current limit is a two (2)-unit limit (billed in ½ hour increments) per seven (7) days.

The Department understands the need for this service, and already has a procedure in place to address the medical need for the service beyond the fee schedule limits.

If the prescribing provider determines that a child has a medically necessary need for Art Therapy beyond what is currently allowable by the MA Fee Schedule, the provider may request approval of additional Art Therapy units through the Department's Program Exception process.

I trust this letter addresses your issues. If you have any further comments or questions, please feel free to contact Ms. Dawn. Poppenwimer, of my staff, at (717) 772-6341.

Sincerely,

Suzanne Love
Director
Bureau of Policy, Budget, and Planning

Commonwealth of Pennsylvania
Department of Public Welfare
Office of Medical Assistance Programs
PO Box 2675
Harrisburg, PA 17105-2675

May 21, 2001

Ms. Lisa M. Lowrie, LSW
Children's Policy Specialist
Pennsylvania Community Providers Association
2400 Park Drive
Harrisburg, Pennsylvania 17110-9303

Dear Ms. Lowrie:

Thank you for your email correspondence of March 23, 2001, regarding Department of Public Welfare (Department) deficiency letters, mailed to providers related to the prior authorization process for Therapeutic Staff Support JSS) services. I will address each comment raised in the email as presented.

1. We have received a number of calls and feedback from members regarding letters sent to them by the Department explaining deficiencies in what was submitted to the Department for the prior authorization of TSS. What is confusing providers is the fact that the information they are told is missing, actually is included in the packet and pretty hard to overlook. Is there something that we are misunderstanding about what is expected or how the information is to be submitted? If it would help, I can gather some examples for you. Please let me know how we can get a clarification on this.

This issue was discussed with staff from the Mental Health Waiver Services Section. While they have noted an overall improvement in documentation submitted, there are still outstanding issues related to Prior Authorization of TSS that could be addressed by the Pennsylvania Community Providers Association (PCPA) as follows:

1) In completing the Medical Assistance (MA)-97: Generally box numbers 1 and 2 are not checked, the address codes are not correct, and the procedure codes and type of services are not correct.

2) In completing the Plan of Care Summary: Generally services are requested for a 4 month time frame; however, the specific dates for the 4 month time frame are not documented. In addition, generally the names and titles of individuals rendering the services are not documented (especially the names).

The Department has concerns over the possibility of dual billing for services in this area; therefore, the name of the individual rendering the service is required. This has led the Department to establish a Quality of Care and Best Practice initiative related to this issue.

3) In completing the Treatment Plan: Generally the submitted Treatment Plans are "standardized" treatment plans established for the particular diagnosis and not specifically geared towards the needs of the individual child. The treatment plan should contain detailed information relevant to the child's current status and the therapeutic milestones (related to improvement or lack thereof) that have or have not been achieved, as well as currently identified goals for the child to achieve. In addition, the treatment plan should include participation expectations related to the caretakers of the child, i.e., parents, guardians, foster parents, and school personnel, as well as the milestones achieved or not achieved by these same caretakers. It is important to stress that the treatment plan documentation is extremely important in evaluating the medical necessity of services that are being requested.

2. The other issue is the issue of billing for Partial Hospitalization (P.H.) and Behavioral Health Rehabilitation (BHR) services on the same day. Can you please provide me with clarification on whether this is something that providers were not to be doing? In the past we were told that the P.H. and BHR services could be billed on the same day but not for the same hours and that you could do this through a Prior Authorization (PA). Has something changed or have we overlooked something?

The procedure code and corresponding fee for day hospitalization/P. H. services are all inclusive, which means that all the services needed to meet the child's needs are included in the reimbursement for the time spent at the facility. This service includes individual, group, and family psychotherapy sessions. Therefore, additional Mobile Therapy and Behavioral Specialist Consultant services should not be needed even during evening hours. Therapeutic Staff Support services outside of the partial program may be requested through the Department's Prior Authorization Process.

The Department has concerns that some day hospitalization/P. H. programs do not seem to be addressing the child as a whole, but rather the child's needs only for the specific period of time spent at the facility. If a child has home and/or "evening hours" issues, the treatment plan for the day hospitalization/P.H. services should also be addressing those issues. In some cases, it has appeared that the child's needs are being "compartmentalized". The day hospitalization/P.H. program's treatment team and treatment plan should address the child's needs for behavior modification related to the home and community environments. If it appears that the child's needs are not being met through the day hospitalization/P. H. services, it may be necessary to re-evaluate the treatment needs and determine more suitable options to address the child's overall needs.

On rare occasions the Department has approved, on an individual basis, additional supports for children who are receiving day hospitalization/P.H. services. The requests for approval of additional services must be made through the Department's Program Exception process. Accompanying documentation would need to provide clinical clarification and justification as to why the additional services are medically necessary, and provide an evaluation of whether or not day hospitalization/P. H. continues to be the most appropriate setting for services being rendered to the child.

I trust this letter addresses your issues. I know some of the answers above appear to be generic and not very case specific in nature. However, it would be almost impossible for the Department to try and address every specific scenario under each question. If you have any further comments or questions, please do not hesitate to contact Ms. Dawn Poppenwimer, of my staff, at (717) 772-6341.

Sincerely,

Suzanne Love
Director
Bureau of Policy, Budget, and Planning

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