Utilization Management Process: ICF-MR Facilities and Level of Care - PowerPoint PPT Presentation

Utilization Management Process: ICF-MR Facilities and Level of Care Requests Presented by Lynnette Gordon, LPC, LCAS- Director of UM and Susan Johnson- Special Populations Specialist February 2013

Review process for requesting Level of Care Successful tips for completing Level of Care process Review internal Utilization Management (UM) process for reviewing Address Concerns and questions

Complete the triplicate Level of Care form Mail and/or hand deliver forms to Eastpointe UM Department c/o Melanie Johnson PO Box 369 514 E. Main Street Beulaville, NC 28518 Treatment Authorization Requests do not have to be submitted through Provider Connect

Every 180 days based upon current facilities UR schedule. Member newly admitted to facility Changes in Level of Care

Status of Request Each Level of Care form request received will be entered by internal Eastpointe staff into the authorization system upon receipt of the form. Status of request is viewable in the Provider Connect system under the Treatment Authorization tab for the requesting provider If unable to see request in the Provider Connect Contact Network Operations Call Center at 1-888-977-2160 and ask to be connected to member

For additional forms Questions regarding the ICF-MR Level of Care authorization process Send an email to utilizationmanagement@eastpointe.net and include in subject line ICF-MR.

Complete the Level of Care (LOC) form completely Please have doctor/psychologist print his/her name below signature Please indicate requested start date on the information submitted Please check all required boxes Submit prior to expiration of current LOC.

Level of Care (LOC) form will be date stamped LOC is entered and TAR created LOC assigned to a licensed Care Manager

Care Manager will review for medical necessity If approved will be return to UM admin staff and completed form will be completed and returned If can not be approved, will be referred to Medical Director for review. Medical Director will approve or deny If denial, will receive adverse decision letter via Provider Connect with appeal process and form will be completed and returned

Mailed copy of the LOC Blank copy of new LOC form Letter from UM regarding reminders and contact information If approved, will indicate approved in Provider Connect If denied Indicate denied in Provider Connect Denial letter will be posted in Provider Connect

All information regarding ICF-MR UM trainings Will be located on the following place on the Eastpointe website: www.eastpointe.net Provider Community- Medicaid Waiver 1915bc- Utilization management

QUESTIONS?