Quality Review Requirements
Quality Review Requirements
The notification of retrospective review sent to the provider will contain a list of specific cases that must be submitted to the review team chosen by a case selection procedure that combines random sampling and cases identified as “high utilization” and “outliers.”
- A. High utilizers are beneficiaries with rate of high utilization.
- B. Outliers are defined as providers who are providing services in an amount that is over and above the average amount of services being provided by their peers.
The review period will be specified in the provider notification letter. The letter will also state the date by which all records must be received by the contractor.
The list of cases to be reviewed will be sent to the provider with a request for certain components of the records.
The information requested includes:
- A. Face Sheet
- B. Initial Certification of Need (CON) and all subsequent CON decisions
- C. Psychiatric Evaluation and all updates
- D. History & Physical and all updates
- E. Intake Assessment and all updates
- F. Psychosocial Assessment and all updates
- G. Nursing Assessment and all updates
- H. Psychological Testing
- I. Psychosexual Assessment if the beneficiary is in a Sexual Offender Program
- J. Treatment Plans: Initial, Master and updates covering the specified period
- K. Progress Notes: Nursing, M.D., Therapy, Shift/Milieu for specified period
- L. All Physician Orders
- M. All Therapeutic Leave of Absence Forms
- N. All Special Treatment Procedures Forms
- O. Initial and Current PCP Referrals
The contractor has the right to request other parts of the health record or the entire record if needed.
The required documentation for retrospective review must meet the general requirements below and must also meet service specific documentation requirements as indicated in the OBHS manual.
- Must be individualized to the beneficiary and specific to the services provided, duplicated notes are not allowed
- The date and actual time the services were provided
- Original signature, name and credentials of the person, who authorized the services
- Original signature, name and credentials of the person, who provided the services, if different from authorizing professional
- The setting in which the services were provided. For all settings other than the provider’s enrolled sites, the name and physical address of the place of service must be included
- The relationship of the services to the treatment regimen described in the Treatment Plan
- Updates describing the patient’s progress
- For services that require contact with anyone other than the beneficiary, evidence of conformance with HIPAA regulations, including presence in documentation of Specific Authorizations, is required
Review is based on tier determination per Independent Assessment.
If the claim indicates a crisis intervention, and this is the only service provided to the beneficiary, the mental health diagnosis is not required.
For reviews where no Independent Assessment has been completed, or when an Independent Assessment resulted in a Tier 1 determination, the following documents are required:
- Provider note
- Mental health diagnosis – must have mental health diagnosis as the first service provided (90791)
- PCP referral, if applicable
For reviews where an Independent Assessment was completed with a Tier 2 or Tier 3 determination, the following documents are required:
- Provider note
- Mental health diagnosis (90791)
- Treatment plan covering the claim service date
- A Psychiatric Assessment covering the claim service date (90792)
Documentation of Prescription for Services: Covered ADDT services require a written prescription signed and dated by the client’s PCP or attending licensed physician. (Section 212.200). Prescriptions for covered services are valid for 1 year unless a shorter time period is specified. Prescriptions must be renewed at least yearly.
Documentation of Qualifying Diagnosis: Clients must have a documented qualifying intellectual or developmental disability diagnosis that originated before the age of 22. Please refer to Section 212.300(B) for a list of qualifying diagnoses.
Documentation of Individual Treatment Plan (ITP):
215.000 Individual Treatment Plan (ITP) | 8-1-22 |
A. Each client receiving covered ADDT services must have an individual treatment plan (ITP).
1. An ITP is a written, individualized plan to improve or maintain the client’s condition based upon evaluation of the client.
2. An ITP must be reevaluated and updated at least annually.
B. Each ITP must at a minimum contain:
1. A written description of the goals and objectives for each covered EIDT service. Each client goal and objective must be:
a. Written in the form of a regular function, task, or activity the client is working toward successfully performing;
b. Measurable; and
c. Specific to each individual client.
2. The specific medical and remedial services, therapies, and activities that will be provided and how those services, therapies, and activities are designed to achieve the client’s goals and objectives;
3. Any evaluations or other documentation that supports the medical necessity of the covered ADDT services specified in the ITP;
4. A schedule of service delivery that includes the frequency and duration of each type of covered ADDT service;
5. The job title(s) or credential(s) of the personnel that will furnish each covered ADDT service;
6. The schedule for completing re-evaluations of the client’s condition and updating the ITP.
Documentation of Covered Services:
202.200 ADDT Documentation Requirements |
8-1-22 |
A. ADDT providers must maintain in each client’s service record sufficient, contemporaneous written documentation demonstrating the medical necessity of all covered ADDT services included on a client’s individual treatment plan (ITP).
B. ADDT providers must maintain in each client’s service record the following documentation for all day habilitative and nursing services performed pursuant to Sections 214.120 and 214.220 of this manual:
1. The specific services furnished each day;
2. The date and beginning and ending time for each of the services performed each day;
3. Name(s) and credential(s) of the person(s) providing each service each day;
4. Which client ITP goal(s) and objective(s) the day’s services are intended to address; and
5. Weekly or more frequent progress notes signed or initialed by the person(s) providing the service(s) describing the client’s status with respect to ITP goals and objectives for that service.
- Prescription for Services: EIDT core services require a written prescription signed and dated by the client’s primary care provider (PCP) or attending license physician. (Section 212.200). Prescriptions are valid for one (1) year, unless a shorter period is specified. Prescriptions must be renewed at least once a year for covered EIDT services to continue.
Documentation of Developmental Screening: For clients who have yet to meet the age requirement for Kindergarten enrollment or who have filed a signed Kindergarten waiver must receive one of the following (Section 212.300):
1. An age appropriate developmental screen administered by the Arkansas Department of Human Services’ (DHS) contracted third party vendor, the results of which indicate the client should be referred for further evaluation; or
2. A developmental screen waiver.
(School age clients receiving covered EIDT services only during the summer when school is not in session do not have to receive a developmental screen.)
Documentation of Comprehensive Development Evaluations for Clients yet to Reach School Age: Clients who have not yet reached the school age (up to six (6) if the Kindergarten year has been waived) must have a documented developmental disability or delay based on the results of an annual comprehensive developmental evaluation to receive covered EIDT services.
Please refer to Section 212.400 for the norm referenced standardized evaluations and criterion referenced evaluations. Evaluations must document that they are administered by qualified evaluators for each instrument and that the test protocol for each instrument were followed.
Documentation of Individual Treatment Plan:
215.000 Individual Treatment Plan (ITP) 8-1-22 A. Each client receiving covered EIDT services must have an individual treatment plan (ITP).
1. An ITP is a written, individualized plan to improve or maintain the client’s condition based upon evaluation of the client.
2. The ITP must be reevaluated and updated at least annually by the Early Childhood Development Specialist (ECDS) assigned to the client.
3. The ECDS’s signature and the date signed must be recorded on the ITP.
B. Each ITP must at a minimum contain:
1. A written description of the goals and objectives for each covered EIDT service. Each client goal and objective must be;
a. Written in the form of a regular function, task, or activity the client is working toward successfully performing;
b. Measurable; and
c. Specific to each individual client.
2. The specific medical and remedial services, therapies, and activities that will be provided and how those services, therapies, and activities are designed to achieve the client’s goals and objectives;
3. Any evaluations or other documentation that supports the medical necessity of the covered EDIT service specified in the ITP;
4. A schedule of service delivery that includes the frequency and duration of each type of covered EIDT service;
5. The job title(s) or credential(s) of the personnel that will furnish each covered EIDT service; and
6. The schedule for completing re-evaluations of the client’s condition and updating the ITP.
Documentation of Covered Services:
202.200 EIDT Documentation Requirements 8-1-22 A. EIDT providers must maintain in each client’s service record sufficient, contemporaneous written documentation demonstrating the medical necessity of all covered EIDT services included on a client’s individual treatment plan (ITP).
B. The service record of a client who has yet to meet the age requirement for Kindergarten enrollment or who has filed a signed Kindergarten waiver must include:
1. Either:
a. A developmental screen administered by the Department of Human Services’ contracted third-party vendor, the results of which indicate the client should be referred for further evaluation; or
b. A developmental screen waiver (See Section 212.300); and
2. The results of an annual comprehensive developmental evaluation (See Section 212.400).
C. The service record of a client enrolled in school must have a documented qualifying diagnosis pursuant to Section 212.500 of this manual.
D. EIDT providers must maintain in each client’s service record the following documentation for all day habilitative and nursing services performed pursuant to Sections 214.120 and 214.140 of this manual:
1. The specific services furnished each day;
2. The date and beginning and ending time for each of the services performed each day;
3. Name(s) and credential(s) of the person(s) providing each service each day;
4. Which client ITP goal(s) and objective(s) the day’s services are intended to address; and
5. Weekly or more frequent progress notes, signed or initialed by the person(s) providing the service(s) describing the client’s status with respect to ITP goals and objectives for that service.
E. EIDT providers must maintain in the client’s service record the documentation specified in Section 204.200 of Section II of the Occupational Therapy, Physical Therapy, and Speech-Language Pathology Services Medicaid manual for all occupational therapy, physical therapy, and speech-language pathology services performed pursuant to Section 214.130 of this manual.
A written referral from the patient’s primary care physician (PCP) requesting an evaluation for the services provided.
A written prescription for the services provided, signed and dated by the PCP or physician specialist dated within 12 months of the dates of service.
All evaluations that support the medical necessity of the services provided.
A treatment plan or plan of care (POC) for the prescribed therapy developed and signed by providers credentialed and licensed in the prescribed therapy or by a physician.
The plan must include goals that are functional, measurable and specific for each individual client.
When applicable, an Individualized Family Service Plan (IFSP), Individual Program Plan (IPP) or Individual Educational Plan (IEP) is required.
For an IEP, pages one (1) and two (2), the Goals and Objectives page (pertinent to the therapy requested) and the Signature Page of the IEP are all that are normally required for verification as review documentation.
- Note: For SpedTrack or similar software, please submit
- All goals and objectives for the type of therapy under review
- Schedule of Services
- Signature page
For the specific time frame of the claim being review, a description of specific therapy service(s) provided with date, actual time service(s) were rendered, and the name and title of the individual providing the service(s) is required.
All therapy evaluation reports and dated progress notes describing the beneficiary’s progress signed by the individual providing the service(s) and any related correspondence.
If the patient is no longer receiving services, copy of discharge notes and a summary are required.
Quality Review/Retrospective Audit
Acentra Health is the Medicaid Quality Improvement Organization (QIO) that is responsible for conducting retrospective reviews of services provided to Medicaid beneficiaries. The Arkansas Department of Human Services, Division of Medical Services, has contracted with Acentra to complete retrospective review of services delivered to Medicaid beneficiaries by doing the following:
- Determine if those services are delivered in accordance with the plan of care and conform to generally accepted professional standards.
- Evaluate the medical necessity of services provided to Medicaid beneficiaries.
- Evaluate the clinical documentation to determine if it is sufficient to support the services billed during the requested period of authorized services.
- Safeguard the Arkansas Medicaid program against unnecessary or inappropriate use of services and excess payments in compliance with 42 CFR 456.3(a).
Audit/Review Training Resources
Accessing Your Audit in the eQSuite Portal
Accessing Your Review
The below information is included on every letter:
- Date of the notice
- Beneficiary name, ID, and DOB
- Provider Name and NPI
- Treatment service
- Case number within eQHealth Solutions Portal
- Claim number
- Dates of services requested
In order to process this request electronically, you will need to register for the portal (click on the link). Below is the information that you will need to register.
- Desired username
- Desired password
- First and Last name
- Email address
- Unit or Department name
- Provider name
- Phone number
- NPI (Found on the Letter)
- Provider Medicaid ID (ID the claim was paid under, found on the claim)
- Address
Click Submit at the bottom of the form and receive 1 of 2 outcomes
You will receive an email with further instructions
OR
You will receive an error message that says “Contact your System Administrator”
Log in and follow the steps on the Quality/Retrospective Review User Guide (click on the link).