Common use of Authorization of Services – Residential Programs Clause in Contracts

Authorization of Services – Residential Programs. A. Pursuant to 42 CFR 438.210(b), the Contractor shall implement mechanisms to assure residential treatment program authorization decision standards are met. B. The Contractor’s residential treatment program standards shall: 1) Establish, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services for residential programs; a) Ensure that residential services are provided in DHCS or Department of Social Services (DSS) licensed residential facilities that also have DMC certification and have been designated by DHCS as capable of delivering care consistent with ASAM treatment criteria; b) Ensure that residential services may be provided in facilities with no bed capacity limit; c) Ensure that the length of residential services comply with the following time restrictions: i. Adults, ages 21 and over, may receive up to two (2) continuous short- term residential regimens per 365 day period. A short-term residential regimen is defined as one (1) residential stay in a DHCS licensed facility for a maximum of ninety (90) days per 365 day period. An adult beneficiary may receive one thirty (30) day extension, if that extension is medically necessary, per 365 day period. ii. Adolescents, under the age of 21, shall receive continuous residential services for a maximum of 30 days. Adolescent beneficiaries may receive a 30 day extension if that extension is determined to be medically necessary. Adolescent beneficiaries are limited to one extension per year. Adolescent beneficiaries receiving residential treatment shall be stabilized as soon as possible and moved down to a less intensive level of treatment. Nothing in the DMC-ODS Pilot or in this iii. If determined to be medically necessary, perinatal beneficiaries may receive a longer length of stay than those described above. d) Ensure that at least one ASAM level of Residential Treatment Services is available to beneficiaries in the first year of implementation; and e) Demonstrate ASAM levels of Residential Treatment Services (Levels 3.1-3.5) within three years of CMS approval of the county implementation plan and state- county Intergovernmental Agreement and describe coordination for ASAM Levels 3.7 and 4.0. 2) Enumerate the mechanisms that the Contractor has in effect that ensure the consistent application of review criteria for authorization decisions, and require consultation with the requesting provider when appropriate. 3) Require written notice to the beneficiary of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in treating the beneficiary’s condition or disease. 4) Have decisions made within the timeframes outlined for service authorizations in 42 CFR 438.210(d), and notices of action related to such decisions provided within the timeframes set forth in 42 CFR 438.404(c). C. Pursuant to 42 CFR 431.201, the Contractor shall define service authorization request in a manner that at least includes a beneficiary’s request for the provision of a service. See General Definitions in Exhibit A, Attachment I for the definition of “Service Authorization Request”.

Authorization of Services – Residential Programs. A. Pursuant to 42 CFR 438.210(b), the Contractor shall implement mechanisms to assure residential treatment program authorization decision standards are met. B. The Contractor’s residential treatment program standards shall: 1) Establish, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services for residential programs; a) Ensure that residential services are provided in DHCS or Department of Social Services (DSS) licensed residential facilities that also have DMC certification and have been designated by DHCS as capable of delivering care consistent with ASAM treatment criteria; b) Ensure that residential services may be provided in facilities with no bed capacity limit; c) Ensure that the length of residential services comply with the following time restrictions: i. Adults, ages 21 and over, may receive up to two (2) continuous short- term residential regimens per 365 day period. A short-term residential regimen is defined as one (1) residential stay in a DHCS licensed facility for a maximum of ninety (90) days per 365 day period. An adult beneficiary may receive one thirty (30) day extension, if that extension is medically necessary, per 365 day period. ii. Adolescents, under the age of 21, shall receive continuous residential services for a maximum of 30 days. Adolescent beneficiaries may receive a 30 day extension if that extension is determined to be medically necessary. Adolescent beneficiaries are limited to one extension per year. Adolescent beneficiaries receiving residential treatment shall be stabilized as soon as possible and moved down to a less intensive level of treatment. Nothing in the DMC-ODS Pilot or in thisthis paragraph overrides any EPSDT requirements. iii. If determined to be medically necessary, perinatal beneficiaries may receive a longer length of stay than those described above. d) Ensure that at least one ASAM level of Residential Treatment Services is available to beneficiaries in the first year of implementation; and e) Demonstrate ASAM levels of Residential Treatment Services (Levels 3.1-3.5) within three years of CMS approval of the county implementation plan and state- county Intergovernmental Agreement and describe coordination for ASAM Levels 3.7 and 4.0. 2) Enumerate the mechanisms that the Contractor has in effect that ensure the consistent application of review criteria for authorization decisions, and require consultation with the requesting provider when appropriate. 3) Require written notice to the beneficiary of any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in treating the beneficiary’s condition or disease. 4) Have decisions made within the timeframes outlined for service authorizations in 42 CFR 438.210(d), and notices of action related to such decisions provided within the timeframes set forth in 42 CFR 438.404(c). C. Pursuant to 42 CFR 431.201, the Contractor shall define service authorization request in a manner that at least includes a beneficiary’s request for the provision of a service. See General Definitions in Exhibit A, Attachment I for the definition of “Service Authorization Request”.