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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT. South Carolina KePRO QIO Request Submission Requirements for RPS. Topics. Service Type(s) KePRO SCDHHS Website Service Type Requirements Contact Information. Prior Authorization Service Type. Mental Health Counseling

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INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT

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  1. INTEGRATED CARE MANAGEMENT AND QUALITY IMPROVEMENT South Carolina KePRO QIO Request Submission Requirements for RPS New 6/14/2012

  2. Topics • Service Type(s) • KePRO SCDHHS Website • Service Type Requirements • Contact Information

  3. Prior Authorization Service Type • Mental Health Counseling • Specific to Psychosocial Rehabilitation (RPS) • Procedure Code – H2017

  4. South Carolina Web Site

  5. Forms Navigate to Form Tab to obtain Fax Document

  6. H2017- PA Submission Request – Fax Form

  7. H2017- PA Submission Request • Required Documentation • Rehabilitative Psychosocial Services Fax Form (See Slide 7) • IPOC • Clinical Presentation • Sample Required Clinical – Documentation should support the members Clinical presentatonDocumentation (see Slides 9- 10) • For PA, individuals must meet the Diagnostic Statistical Manual of Mental Disorders, Current Edition, Text Revision (DSM-IV-TR) diagnostic criteria for an Axis I or Axis II Mental Health Disorder.

  8. H2017- PA Submission Request Eligibility of Services for RBHS/Diagnosis Criteria: • Confirmed Psychiatric Diagnosis from the current edition of the DSM - IV or Current ICD.  • V – Codes - Use of V-codes is allowed under certain circumstances, but in general is considered temporary (See RBHS Manual section 2-9 for further clarification) • V- Codes may not be used for ages 7 and up for longer than a six month duration (See RBHS Manual section 2-9 for further clarification) • Exclusions: Unless they co-occur with a serious mental disorder that meets current edition DSM-IV criteria.   • Irreversible Dementias • Mental Retardation • Developmental disorders

  9. H2017- PA Submission Request • Sample Required Clinical Documentation • Describe Symptoms/Severity of illness: • Individual must exhibit significant functional impairments in major life activities due to a mental, behavioral, or emotional illness. • Must meet two of the following: • Have difficulty establishing or maintaining normal interpersonal relationships to the degree they are at risk of hospitalization, homelessness, or isolation from social supports; or • Have behaviors that require repeated interventions by the mental health, social services or judicial system; or • Be unable to recognize personal danger or significantly inappropriate social behavior; or • Require help in basic living skills to such a degree that health or safety is jeopardized.

  10. H2017- PA Submission Request Sample Required Clinical DocumentationIndividual must meet one of the following: • Have experienced long-term or repeated psychiatric hospitalizations; or • Lack daily living skills and interpersonal skills; or • Have limited or non-existent support system; or • Be unable to function in the community without intensive intervention; or • Require long-term services to be maintained in the community.

  11. KePRO Contacts

  12. Thank You! 12

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