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PCPA Responds to TSS Prior Authorization Draft Bulletin
November 10, 2000

PCPA members had the opportunity to respond to the recently released draft bulletin from the Office of Medical Assistance Programs governing the prior uathorization of TSS Services. Following receipt of input Lisa Lowrie, Children's Policy Specialist, sent the following response to the Office of Medical Assistance Programs. PCPA thanks the providers who offered comment on the draft. Additional questions about this bulletin or other Behavioral Health Rehabilitation Services (BHRS) for children can be directed to Ms. Lowrie at the Association.

Ms. Suzanne Love
Office of Medical Assistance Programs
Bureau of Policy, Budget & Planning
226 Cherrywood Bldg., #33
Harrisburg, PA 17105

Dear Ms. Love:

The Pennsylvania Community Providers Association (PCPA) is a trade association representing over 220 community-based agencies that provide mental health, mental retardation, substance abuse, children’s, and other human services. Our members cover all 67 counties in the Commonwealth. We thank you for the opportunity to comment on the TSS Prior Authorization bulletin. Included are our comments on the procedures outlined for requesting Prior Authorization of TSS services and a brief response on Safeguards for Prompt Review.

PCPA has begun to work with our providers as well as two other professional organizations, the Pennsylvania Psychiatric Society and the Pennsylvania Psychological Association, to develop clinical standards and models of care for children.

After reviewing the new draft for TSS Prior Authorization, we were pleased to see that the Department had taken some of our concerns from previous responses into consideration. Specifically, thank you for the safeguards you developed to ensure access to services. We still must emphasize our concern with the implementation of prior authorization. In the past the provider packets have been lost when sent to the OMAP. Although OMAP has hired more staff to ensure timeliness of services, there is still the issue of how providers will receive verification that the packets are received. We request that providers are notified when all documentation is received by the OMAP Prior Authorization Unit. Providers have a long history of incidences where their information was lost even when a return receipt was signed by DPW staff. We request that notification be provided within 24 hours of DPW's receipt. Also, if providers have questions regarding their packet who are they to contact at OMAP?

Providers are concerned that the prior authorization, even with good intentions, procedures, and safeguards, could in fact delay services to children in need. Suggestions from providers include allowing providers to bill off the fee schedule for the initial 30 to 60 days of TSS services. This would give providers time to gather the appropriate data while ensuring that children are receiving services that are medically necessary. Please reconsider your prior authorization period and allow flexibility so providers are able to get children and their families the services they need in a timely manner.

Please also allow providers four (4) to six (6) months after the issuance of the bulletin to prepare for the changes and additional requirements placed upon them.

Specific Issues related to the draft bulletin:
Background
In the background information one bulletin was forgotten. That bulletin was 50-98-04, Accessing Outpatient Behavioral Health Services Not Currently on the Medical Assistance Program Fee Schedule for Eligible Recipients Under 21 Years of Age. Please add this to ensure all background information is consistent. If there was a reason for the omission please explain why.

Discussion
Psychiatric/Psychological Evaluation

1. Identifying information that fully describes the child
h. Please include grades repeated, eligibility for special education, educational placements tried, a copy of the Comprehensive Evaluation when the child is identified as eligible for Special Education, and a copy of the Behavioral Support Plans.

i. Please add to this section Developmental History (including relevant prenatal history, early milestones, identification of any early illnesses or injuries, and relevant residential history).

Treatment Plan
In the past we have requested a clarification on the age of consent. In section (3)(c)(5) it is stated that the signature of parent/guardian and child if 14 years of age or older is required. Does this mean that the services are to be performed even if the parent or child refuses to sign the treatment plan?

The following are our comments on the Procedures to Request Prior Authorization and Submit Claims for TSS Services.

A. Procedures to Request Prior Authorization of TSS Services
Submission Address
Can submissions be provided electronically? If so, to whom would the information be submitted?

Timeframe For Submission
The timeframe for submission has been reduced from the current 45 days prior to the authorization date to 30 days. This reduces time providers have to gather the information needed including the Psychiatric or Psychological Evaluation. Please replace the draft language with the current language. If not this reduction will significantly affect children's access to service in a timely manner. Providers are under a number of constraints including a shortage of staff causing human resource hardships. The draft language for submission will force providers to complete all monthly evaluations in a two-week period. Providers also inform us that children are waiting for psychiatrics and psychological evaluations to be performed. This impedes the provider's ability to submit the packet within the time frame allotted.

Effective Date of Approval
Please provide us with the expectation for providers in relationship to the draft bulletin and the time frames required for a child with an initiation of services December 2000. Providers would like clarification on what procedures they are to follow when services are initiated in December but to begin on February 1. Can you please clarify?

The requirement for TSS Prior Authorization will force providers to attain more than three (3) psychological evaluations a year. The Medical Assistance fee schedule only allows for three to be billed. Will Medical Assistance change the current allowance so that providers are able to bill for the additional evaluations?

Incorrect or incomplete requests
Will Medical Assistance accept additional information or corrected information by way of Internet, fax, or must it is provide through the mail system?

Notice of OMAP's Decision
Please allow providers to bill weekly or bi-weekly so they may avoid a cash flow crisis.

Processing changes in prescription
Please clarify for us the following issues related to increases and decreases in prescriptions:

  • If a child responds to the BHRS more quickly than anticipated, must the provider continue to provide the amount of hours prescribed until the OMAP is notified?
  • Must the Psychiatric/Psychological Addendum be a face to face?
  • If the addendum must be completed, please increase the MA fee schedule allowance of three (3) psychological evaluations per year. It is essential that providers have the ability to obtain the evaluations quickly and be paid for the services they provide.
  • Will providers be notified if the change in prescription is accepted or rejected? An example would be the child in need of more intensive services; will the families and providers have to begin the PA process again or is the notification to OMAP acceptable?
  • Must the Department be notified if the decreases in prescription are due to a shortage of staff?

Appeal Process for Families and Providers
Please add a section that explains the appeal process for families and providers if the request for service is denied.

B. Expedited Review Process
This section is the most controversial. Seven days is very long time for child on the brink of admission to a residential facility or inpatient hospitalization or in the midst of a family crisis. The seven-day time frame is based on the assumption that everyone involved in the process from the county to DPW will work quickly.

  • What is the time frame for the County to send in the completed form to the State?
  • What is the time frame for the Field Office to submit the information to OMAP?

C. Prior Authorized TSS Services Claims Submission
We reiterate that providers should have the ability to bill more than once a month to alleviate a cash flow issue.

While reviewing this section we were aware that Prior Authorization and Program Exception were used interchangeably. Our understanding is that they are separate processes. Can you please provide us with a clarification?

On behalf of the members of PCPA, thank you for the opportunity to provide you with our input. Please feel free to contact me should you have any questions.

Sincerely,

Lisa M. Lowrie, LSW
Children's Policy Specialist

cc: Charles Curie, OMHSAS
Joan Erney, OMHSAS
Jerry Kopelman, OMHSAS

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