9 CSR 45-2.017 - Utilization Review Process
(1) Definitions.
(A) Authorization-Approval notice to a
provider that a specific amount of service at a specific rate may be provided
to an individual.
(B) Budget-The
total cost of services and supports funded through the division recommended or
approved to meet an individual's needs identified in an Individualized Support
Plan. Services and supports paid for outside of the department billing system
are excluded from the budget.
(C)
Department-Department of Mental Health.
(D) Division-Division of Developmental
Disabilities.
(E) Emergency
criteria consist of one (1) or more of the following:
1. The individual is in immediate need of
life-sustaining services (food and shelter, or protection from harm) and there
is no alternative to division funding or provision of those services;
2. The individual needs immediate services in
order to protect self or another person from imminent physical harm;
3. The individual is residing in an
intermediate care facility for persons who have developmental disabilities
(ICF/DD) or a skilled nursing facility (SNF) and has been assessed as able to
live in a less restrictive arrangement in the community, the individual wants
to live in the community, and appropriate services and supports can be arranged
through the waiver;
4. The
individual had been receiving significant services through division
waiver-funded programs and services, is evaluated to still need the significant
level of services, but is no longer eligible for the program or services due to
age; or
5. The individual is in the
care and custody of the Department of Social Services, Children's Division,
which has a formal agreement in place with the division to fund the costs of
waiver services for the specific individual or for individuals who are in a
Voluntary Placement Agreement (VPA).
(F) Missouri Adaptive Ability Scale (MAAS)-A
norm-referenced, standardized assessment of functional ability. The MAAS shall
be used to determine number and severity of functional limitations for
eligibility, prioritization of need score, and rate setting.
(G) Person-centered planning process-A
process directed by the individual, with assistance as needed from a guardian,
public administrator, the responsible party, or other person as freely chosen
by the individual. The process may include other individuals freely chosen by
the participant who are able to serve as important contributors to the process.
The person-centered planning process enables and assists the individual to
access a personalized mix of paid and non-paid services and supports that will
assist him/her to achieve personally defined outcomes and the training,
supports, therapies, treatments, and/or other services become part of the
ISP.
(H) Prioritization of need
(PON) score- A component of the MAAS that quantifies the level of impairment of
an individual and is used to determine priority of access to services. The PON
score is expressed on a one (1) to five (5) scale with five (5) being the
highest possible score.
(I)
Responsible party-The parent(s) of a minor child, spouse, court appointed
guardian, public administrator, or any other person who has legal authority to
make decisions for a person served by the division.
(J) Senate Bill 40 County Developmental
Disability Boards (SB40 Board)-County boards established pursuant to section
205.970, RSMo, to provide
services with voter approved tax levies to residents of that county who are
handicapped persons as defined in sections
178.900 and
205.968, RSMo.
(K) Individualized Support Plan (ISP)-A
document directed by the individual, with assistance as needed from a
representative, in collaboration with a planning team. The ISP identifies
strengths, capacities, preferences, needs, and desired outcomes of the
individual. The ISP shall encompass personalized mix of paid and non-paid
services and supports that will assist him/her to achieve personally defined
outcomes. Training, supports, therapies, treatments, and/or other services to
be provided for the individual become part of the ISP.
(L) Service/Support-Informal and formal means
of meeting needs identified in the ISP.
(M) Utilization Review (UR)-A formal process
at the regional office to review PON, proposed ISPs, and budgets and make
recommendations for approval, modification, or denial of the requested
services. The regional director or assistant regional director has the
authority to review and approve recommended services and may designate
individuals to review and approve recommended services. The authority to deny
or modify requested services lies solely with the regional director or
assistant regional director.
(2) Following the establishment of
eligibility for division services in accordance with
9 CSR
45-2.010, the person-centered planning process begins.
An ISP is developed through discussion with the individual and/or guardian and
with input from others as directed by the individual and/or guardian. The ISP,
budget, and PON (if applicable), are then submitted to UR, and a copy of the
ISP, budget, and PON (if applicable), is provided to the individual and/or
guardian.
(A) A PON score is necessary when
there is a request to begin participation in any waiver.
(B) A new assessment of PON shall be
completed when an individual on a waiting list experiences a change in personal
circumstances, environment, or family situation impacting level of
need.
(C) UR is necessary under the
following circumstances:
1. When individuals
will be receiving funded services for the first time;
2. When the individual's ISP and budget is
amended by adding new services or increasing the dollar amount of a specific
service;
3. When individuals who
are participating in the Partnership for Hope waiver move from a participating
county into one that does not participate in the Partnership for Hope waiver;
or
4. Any other situation at the
discretion of the regional director.
(D) UR is not necessary when there is no
change to the ISP or budget, but the ISP may be reviewed at the discretion of
the regional director.
(E) In
emergency situations as described in paragraphs (1) (E)1.-5. of this rule, the
regional director has the authority to approve an increase in a ISP to protect
the health and safety of an individual and to subsequently report the decision
to the support coordinator who will develop an ISP amendment.
(3) Following implementation of
the initial ISP and annually thereafter, two (2) months prior to the proposed
ISP and budget implementation, the service coordinator shall meet with the
individual, the individual's family, and as appropriate the individual's
responsible party to prepare an ISP and budget with justification for the
individual's support needs.
(A) The ISP and
budget shall be agreed to and the ISP shall be signed by the individual and/or
responsible party.
(4)
One (1) month prior to the proposed ISP and budget implementation, the service
coordinator shall submit the signed ISP to the regional director or the
regional director's designee for approval. Plans submitted that include
services with a start date less than thirty (30) days from the implementation
date shall not expedite approval timelines.
(A) If the ISP and budget submission to UR
shall otherwise be delayed due to the inability of the service coordinator to
obtain the signature of the individual or responsible party, then the ISP and
budget shall be forwarded to UR without the signature and a copy of the ISP and
budget shall be mailed to the individual or responsible party.
(5) UR shall recommend for
approval a service/support for inclusion on a prioritized waiting list if the
service/support meets each of the following criteria:
(A) Need for the service/support is
documented in the ISP as necessary for the individual's health, safety, and/or
independence and alternative funding or programs are not available to meet the
need;
(B) Need for the
service/support is specifically related to the person's disability (i.e., not
something that would be needed regardless of the person's disability);
and
(C) Individuals evaluated with
needs meeting emergency criteria receive highest priority in receiving funding
for services.
(6) The
division shall maintain a waitlist for entry into the Division of Developmental
Disabilities waiver- funded services. The regional office enters individuals on
a prioritized waiting list when services requested in an approved ISP require
entry into a waiver. Individuals evaluated with needs meeting emergency
criteria receive highest priority in receiving funding for services.
(7) UR shall review the ISP, budget and PON
(when required) within six (6) business days of receipt. A PON score based on
the emergency criteria will be reviewed by the regional director or their
designee for verification.
(A) If sufficient
information is submitted, the regional director or the designee may approve the
ISP and budget. The regional director or designee has five (5) business days to
render a decision.
(B) If more
information is needed or changes are necessary in the budget or service
authorization associated with a ISP, that information shall be requested from
the service coordinator, who has ten (10) business days to respond. Upon
receipt of the requested information or following the conclusion of these ten
(10) business days, the regional director or designee will then have five (5)
business days to render a decision.
(8) Following the decision by the regional
director or designee, a decision letter and the completed ISP and budget shall
be provided within ten (10) business days of the decision to the individual
and/or responsible party, service coordinator, and provider(s). If the regional
director disapproves or modifies an ISP and budget, the regional director shall
include in the decision letter the reason(s) for the disapproval or
modification and must provide information on rights to appeal.
(9) The individual or responsible party may
appeal the decision, in writing or verbally, to the regional director or
assistant regional director within thirty (30) calendar days from the date of
the decision letter.
(A) If necessary,
appropriate staff shall assist the individual or responsible party in making
the appeal.
(B) The regional
director or designee may meet with the individual or responsible party and any
staff to consider any information relevant to the final decision and to hear
any comments or objections related to the decision.
(C) Within ten (10) business days after
receiving the appeal, the regional director or designee shall notify the
individual or responsible party in writing of the decision.
(10) When the decision, as set
forth in section (8) above, results in any individual being denied service(s)
based on a determination the individual is not eligible for the service(s) or
adversely affects a waiver service for an individual, the individual and/or
responsible party may appeal in accordance with the procedures set forth in
9 CSR
45-2.020(3)(C).
(A) An individual and/or responsible party
participating in a Division MO HealthNet/Medicaid waiver program has appeal
rights through both the Department of Mental Health and the Department of
Social Services. Those individuals may appeal to Department of Social Services
before, during, or after exhausting the Department of Mental Health appeal
process. Once the appeal process through Department of Social Services begins,
appeal rights through the Department of Mental Health cease. Individuals
appealing to the Department of Social Services must do so in writing within
ninety (90) calendar days of written notice of the adverse action to request an
appeal hearing. Requests for appeal to the Department of Social Services should
be sent to MO HealthNet Division, Constituent Services Unit, PO Box 6500,
Jefferson City, MO 65102-6500, or call Constituent Services Unit at 1 (800)
392-2161.
(11) If an
individual and/or responsible party timely files an appeal of a decision,
services currently being provided under an existing ISP will not be suspended,
reduced, or terminated pending a hearing decision unless the individual or
legal representative requests in writing that services be suspended, reduced,
or terminated.
(A) The individual and/or
responsible party may be responsible for repayment of any federal or state
funds expended for services while the appeal is pending if the hearing decision
upholds the director's decision.
(12) The service coordinator shall provide
guidance to the individual, family, and the responsible party about any
alternative resources potentially available to support needs that are not
approved through the UR process.
(13) New services/supports that result in an
increase in the total budget shall not begin before the ISP and budget are
approved through the UR process and approved by the regional director or
designee, except in an emergency situation approved by the regional director or
designee. Services approved due to an emergency situation may not exceed sixty
(60) calendar days. An extension of up to an additional sixty (60) calendar
days may be requested in writing and may be approved in writing at the
discretion of the regional office director.
(14) Budgets are determined by the total cost
of all services and supports paid through the billing system of the department.
Services and supports paid for outside of the department billing system are
excluded.
(A) When multiple family members are
receiving division services, this shall be noted. All of the budgets shall be
considered together in the utilization review process in order to have a
comprehensive picture of all services/supports going into a single home so the
necessary level of services can be determined. This does not require each
family member's ISP be on the same plan year, but does require all of the
current supports in the home be considered.
(B) Applicable Medicaid State Plan services
shall be accessed first when the individual is MO HealthNet-eligible and the
services will meet the individual's needs.
(15) A review, modification in units, or
denial of a service should not delay the implementation of other services in
the plan.
(16) Other ISP and budget
reviews shall continue to be completed by the service coordinator and/or
service coordination supervisor, as directed by the regional
director.
Notes
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