Gateway Community Health Provider Manual September 2010

Gateway Community Health Provider
Manual
September 2010
1
Table of Contents
Table of Contents................................................................................................................................2
Section I
Introduction ................................................................................................................................ 5
Purpose of the Manual..............................................................................................................5
About Gateway ..........................................................................................................................5
Mission Statement.....................................................................................................................6
Contact Information ...................................................................................................................6
Choice within Gateway Community Health ........................................................................6
Eligibility and Enrollment ......................................................................................................7
Intake Assessment ..............................................................................................................7
Section II
Network Management & Provider Relations ................................................................................. 9
Introduction ..................................................................................................................... 9
Network Contracting Process ..............................................................................................9
Credentialing ................................................................................................................. 11
Fair Employment Practices (FEP) Process and Application ......................................... 12
Criminal Background Checks .......................................................................................... 14
Model Payment System (MPS) – Title XIX .................................................................... 14
Provider Sanctions............................................................................................................ 19
Section III
Information Management/Claims Processing ........................................................................ 22
Introduction ........................................................................................................................ 22
Claims Submission Methods................................................................................................. 22
Electronic Claims Submission .......................................................................................... 22
Claims Processing ............................................................................................................ 23
Coordination of Benefits (COB) ........................................................................................ 23
ICD-9-CM Codes/Billing Codes........................................................................................ 24
Filing Limits/Forms ................................................................................................................. 24
Explanation of Benefits/Remittance Advise ..........................................................................27
Claims Appeal Process.......................................................................................................... 28
Fraud and Abuse .......................................................................................................... 28
Section IV
Financial Management ............................................................................................................30
Introduction ........................................................................................................................ 30
Ability to Pay ...................................................................................................................... 30
Claims Verification .................................................................................................................. 31
Medicaid False Claims Act ............................................................................................... 32
2
Section V
Clinical Services .......................................................................................................................34
Introduction .........................................................................................................................34
Emergency Procedures ..........................................................................................................34
Person Centered Planning ................................................................................................34
Crisis Planning .................................................................................................................. 39
Advanced Directives ...............................................................................................................40
Coordination of Care ...............................................................................................................41
Psychiatric Consultations on a Medical Floor..................................................................42
Targeted Case Management .................................................................................................43
Requirements for Community Living Support Staff and Respite Workers....................47
Verification Guidelines for Community Living Support Staff and Respite Workers......49
Section VI
Utilization Management .................................................................................................................50
Introduction .........................................................................................................................50
Definitions.................................................................................................................................50
Authorization Process .............................................................................................................52
Utilization Guidelines and Management ........................................................................... 53
Inpatient Hospitalization and Partial Hospitalization Clinical Appeals ...........................54
Discharge Day in a 24 Hour Setting .................................................................................. 57
Residential Reconsideration Review................................................................................. 57
Section VII
Quality Improvement ................................................................................................................ 59
Introduction .........................................................................................................................59
Contact Information .................................................................................................................59
Incident Reporting ................................................................................................................... 59
Death Reporting............................................................................................................ 59
Sentinel Events ..................................................................................................................60
Residential Monitoring.............................................................................................................61
Monitoring of Consumer Funds.............................................................................................. 62
Emergency Preparedness......................................................................................................63
Vehicle Safety ............................................................................................................... 64
Section VIII
Compliance .............................................................................................................................. 66
Provider Monitoring & Site Visits ............................................................................................ 66
Medicaid Claims Audit ............................................................................................................67
Anti-Kickback Law ........................................................................................................ 68
Section IX
Member Services/Customer Services ..................................................................................... 69
Introduction .........................................................................................................................69
Customer Service/Member Service Functions ................................................................. 69
Cultural Competency ..............................................................................................................70
Limited English Proficiency ................................................................................................ 73
3
Section X
Introduction .....................................................................................................................................77
Grievance and Appeals .....................................................................................................77
Section XI
Recipient Rights ....................................................................................................................... 79
Introduction .........................................................................................................................79
Section XIII
Miscellaneous .......................................................................................................................... 80
Preliminary Death Report Form ........................................................................................... 81
Report of Recipient Death..................................................................................................... 82
Sentinel Event Report ............................................................................................................ 86
Glossary .............................................................................................................................88
Section XIII
Addendums ............................................................................................................. 108
PIHP/CMHSP Encounter Reporting HCPCS and Revenue Codes ............................108
Medicaid Application ....................................................................................................... 108
Medicaid Provider Manual .............................................................................................. 108
Michigan Department of Community Health Approved Diagnosis Codes................. 108
Person Centered Planning Best Practice Guideline .................................................... 108
Consumerism Best Practice Guideline ......................................................................... 115
Self-Determination Policy & Practice Guideline ........................................................... 119
Housing Best Practice Guidelines .................................................................................. 131
4
Section I
Introduction
The following document comprises the Gateway Community Health (Gateway)
Provider Manual. Gateway also issues and distributes periodic bulletins and written
notices as changes are implemented to the policies and/or processes described in the
manual at its provider meetings, on the Gateway on-line provider portal or through email. These bulletins and written notices are immediately effective when distributed or
as otherwise indicated, and replace and take precedence over similar material,
previously distributed. An inventory of these bulletins and written notices is maintained
in and can be accessed by contacting the Provider Service Department. These bulletins
and notices are incorporated into the online version of the manual on an annual basis.
This manual serves as a ready reference tool for professional providers. Please be
advised that this manual does not replace or eliminate any provider requirements or
obligations contained in individual provider contracts and in all instances is to be
interpreted in accordance with the terms and requirements contained in those contracts.
Any discrepancies between this Manual and individual provider contracts shall be
resolved in favor of the terms of such contracts.
Purpose of the Manual
Gateway Community Health developed this manual to supply providers with details on the
structure, policies and procedures of Gateway. We recommend that providers and their
staff read this manual and reference it as necessary.
About Gateway Community Health
Gateway Community Health, Inc. is a Michigan non-profit corporation, operating as
a Manager of a Comprehensive Provider Network (MCPN) in Wayne County,
Michigan. Gateway is funded by the Detroit-Wayne County Community Mental
Health Agency (DWCCMHA).
The Michigan Department of Community Health, in their revised plan for procurement,
required Detroit-Wayne County Community Mental Health Agency to develop a vertically
integrated network of Provider of Specialty Service Networks (PSSN) to ensure choice for
persons receiving publicly funded mental health services. The Managers of
Comprehensive Provider Networks are the Agency PSSNs.
The MCPNs under the Detroit-Wayne County Community Mental Health Agency are to
provide mental health and substance abuse services for persons with, or at risk for, serious
emotional disturbance, severe mental illness, developmental disabilities, substance
abuse, and MIChild beneficiaries. The system is designed to give individuals, within the
identified populations, greater choice and involvement in their treatment.
5
The cornerstones of this system are: (1) providing choice; (2) Person-Centered
Planning principals; and (3) maximizing the use of and developing new communitybased services. Services are provided through the Managers of Comprehensive
Provider Networks, Substance Abuse Coordinating Agencies, and other Agency
contractors.
As a MCPN, Gateway contracts with DWCCMHA. MCPNs were established to
develop and manage a comprehensive network of providers who meet the needs of
individuals with or at risk of developing severe mental illness, serious emotional
disturbance or developmental disabilities. The ultimate goal of the Detroit-Wayne
County Community Mental Health Agency and each MCPN is to provide choice and
access to quality care and services in a cost-efficient manner.
MCPNs are not managed care plans and not insurance companies.
Mission Statement
Gateway Community Health will ensure access to a contracted network that provides
comprehensive, culturally competent mental health and substance abuse services for
children, adults, seniors and their families. These services will support recovery,
independence, collaboration and empowerment within the home and community.
Contact Information
Address: 3011 West Grand Boulevard
Suite 2000
Detroit, Michigan 48202
Toll Free: (800) 973-GATE (4283)
Main Telephone: (313) 262-5050
TDD: (313) 875-4065
Choice within Gateway Community Health
As stated in the definition of an MCPN, Gateway does not directly provide services or
supports. Gateway is responsible for contracting and overseeing qualified, competent,
Medicaid-approved providers to meet the needs described in the Person-Centered Plan.
To meet this requirement, Gateway currently has contracts with many approved provider
sites offering a wide array of services.
Once a provider is selected the beneficiary will have choice, within certain limits,
regarding the specific staff person providing the service or support. Choice may be limited
by such things as caseload size and availability of other comparable staff within that
provider location.
In addition to the choice of staff and the choice of provider sites, the beneficiary has the
option of choosing another MCPH on a monthly basis.
6
Eligibility and Enrollment
This section contains information on how to determine eligibility and enroll a beneficiary
into the system for Detroit-Wayne County Community Mental Health Agency under
Gateway Community Health
ELIGIBILITY
To be eligible as a Gateway Community Health consumer, the individual must be a
Wayne County resident with or at risk of developing a serious mental illness. Please
refer to the glossary for definitions on serious emotional disturbance and serious mental
illness.
Based on the Michigan Mental Health Code, services are available to eligible persons
regardless of ability to pay.
ENROLLMENT
Providers may check an individual‘s MCPN assignment via the web-based MH-WIN
system if they have access to this system. If the provider does not have access to MHWIN, they may contact Pioneer Behavioral Health at 1-866-690-8257 or Gateway‘s
Customer Service Department at (313) 262-5050 to request this information. If the
member is not enrolled in an MCPH, the intake assessment must be completed via the
intake e-form process.
Enrollment and Re-enrollment process:
1. Providers must call Pioneer at 1-866-690-8257 in order to begin the enrollment
process.
2. Pioneer will ascertain whether the consumer meets initial eligibility.
3. Consumers who meet initial eligibility will be defaulted into the MCPN of their
choice.
4. Consumers presenting in a crisis situation will be re-enrolled into their previously
assigned MCPN, if applicable.
5. Consumers presenting on a routine basis will be re-enrolled to their previous
MCPN or the MCPN of preference if applicable.
6. The MCPN start date will be the date Pioneer receives the information allowing
them to make a determination of initial eligibility (usually the first day)
7. Providers are to conduct an assessment and complete the eligibility E-form on
the MH-WIN system and submit the form electronically.
8. An enrollment form should be completed and signed by the consumer and/or
guardian and mailed to the Detroit-Wayne County Community Mental Health
Agency.
9. All provider calls related to enrollment are to be routed to Pioneer for disposition.
Intake Assessment
1. Providers are to complete the Intake Assessment Form on all Persons
presenting for services who are either:
New to the system or
Are in the system but do not have an MCPN Assignment (Check MH-WIN)
7
2.
3.
4.
5.
This form may be completed hard copy, but the information MUST be
entered by the provider completing the intake assessment directly onto MHWIN using the Intake E-form process. Pioneer will no longer accept hard copy
(paper) versions of this assessment.
Important: Indicate the MCPN Affiliation by checking the appropriate box on
the top of the form on page 1.
Maintain a log of all assessments submitted indicating Person‘s name and
the date the information was submitted.
Providers must perform and document an ability to pay determination and
billing determination for identification of first and third payor parties during
the intake assessment, and at least annually thereafter.
8
Section II
Network Management & Provider Relations
Introduction
The Network Management Department is responsible for maintaining all contracts and
requirements for contracted providers.
The Provider Relations Department serves as liaisons to the provider network.
Applications for becoming a panel provider are available on the website at
www.gchi.org or by contacting the Provider Relations Department.
Contact Information:
Lynch Travis
Director, Provider Relations
313-263-2368
ltravis@gchi.org
H. Michael Falconer
Director, Network Management
313-263-2398
hfalconer@gchi.org
Barbara Tamachaski
Provider Information Changes
313-263-2414
btamachaski@gchi.org
Sharon Tye
Provider License, Insurance and
other Required Information
Updates
313-263-2352
stye@gchi.org
Darlene Williams
Provider Applications & Liaison
313-263-2464
dwilliams@gchi.org
Network Contracting Process
Any entity interested in becoming a panel provider for Gateway must follow the
network‘s contracting process.
Application Process - all applicant providers are required to complete an application to
be considered for panel provider status. All requests are handled by the Network
Management Department. The applicant provider is required to complete the application
in its entirety and submit to the Provider Relations Liaison along with the required
documentation as listed in the application.
Only when the application is complete will it be reviewed by Network Management.
Network Management will review submitted applications for consideration as a panel
provider.
9
The review will take into consideration the applicant‘s history of service to the target
population, the need for service in the applicant‘s geographic area, provider rates,
recipient rights, quality of care, results of a site visit and other pertinent information
available at the time of the review.
Network Management forwards providers who are recommended for contracts to the
Chief Executive Officer (CEO). The CEO reviews and either approve and executes the
contracts, or deny the recommendation. Applicants will be issued written notice within
approximately five (5) business days of the decision regarding the status of their
application. Applications may be approved, pended or denied at this point.
Approved applicants will receive a fully executed contract, their provider number and
claim submission information.
Denied applicants will be issued a notice within five (5) business days of the decision.
Denied providers will be given an opportunity to request reconsideration of the decision
within thirty-days (30) of the date of the denial letter.
Request for Reconsideration - Applicants who have been denied a contract with
Gateway are afforded the opportunity to request reconsideration of the decision.
Applicant provider has 30 days from the date of the notification to file such request.
Applicant must submit their request in writing to the Director of Network Management.
Applicant must indicate reason for the request and any other documentation that may
be necessary for further review. The Director of Network Management, or designee, will
notify the applicant of the receipt of their request for reconsideration within 7 days. The
reconsideration applicant will be notified of the final disposition within approximately 7
days of the determination.
Applications may be pended by Network Management Workgroup or the CEO based on
several factors which could include requests for additional information, contracted
providers who are on plans of correction.
The Director of Network Management, or designee, is responsible for informing the
provider of the network‘s decision regarding a contract. Documentation of all
applications, committee notes and contracts shall be the responsibility of the Director of
Network Management and maintained within the Network Management Department. All
applications and applicant information will be kept on file for a minimum of two (2) years.
Once approved for contract, providers are contract document based on the type of
service(s) to be rendered. Providers are then invited to a provider orientation meeting
to become acclimated to the network‘s policies and procedures. Providers are given
appropriate information regarding billing/claims, network processes and procedures,
recipient rights information and other information the provider needs to operate with the
network.
10
Provider contracting is secondary to meeting the needs of the consumer. There will be
occasions where contracts will be issued outside of the normal Network Management
structure due to an emergency or urgent situation in an effort to appropriately treat or
place a consumer. The provider must be licensed for the type of service that will be
rendered to the consumer in order to bill for those services (for example, licensed to
service the mentally ill population if placing in an Adult Foster Care Home). They must
meet minimum contracting requirements including the minimum liability insurance
requirement. For out-of-network providers, a Letter of Agreement may be issued that is
specific for one consumer.
Credentialing
The Director, Network Management is responsible for oversight regarding the
credentialing of providers which includes the initial credentialing through the contracting
process and continued re-credentialing. Providers that are not credentialed are notified
by the Director of Network Management or Pioneer Behavioral Health.
It is the policy of Gateway that all contracted service providers are appropriately
credentialed to provide such services as listed in their Gateway contract.
Gateway utilizes various methods to assure credentialing of service providers as an
organization or in the case of children‘s services, individually.
Gateway seeks to develop and maintain a network that provides a continuum of care
that allows members to be served in the most appropriate levels of care and in the least
restrictive environment.
Careful evaluations of programs and individuals that are credentialed based on
accreditation and licensure for service specific populations is paramount.
Administrative credentialing is performed and involves verification of the following:
Good standing with the State of Michigan and Federal regulatory agencies
Lack of Medicaid and Medicare sanctions
Current State of Michigan licensure and/or certification if applicable
Professional and general liability insurance coverage as noted in the contract
Compliance with contractual requirements regarding malpractice claims history
Completion and submission of all required application documents pertaining to
current accreditation
Wayne County Fair Employment Practices certificate
Not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any federal department or
agency
Prompt and effective response to any Recipient Rights findings, grievances, or
other complaints, or service delivery concerns
11
Participate as appropriate in on-going administrative and clinical/service delivery
monitoring and continuous quality improvement efforts
Fair Employment Practices (FEP) Process and Application
All contracted providers are required to maintain a current Fair Employment Practices
Certificate through Wayne County. Applications can be obtained from Wayne County‘s
web site at www.epurchasing.waynecounty.com or by calling Wayne County at (313)
224- 5021. You can also contact Gateway Provider Relations Department.
The applications must be submitted to Human Relations Division, 600 Randolph, 5th
Floor, Detroit, Michigan 48226. Their fax number is (313) 224-6932.
Providers must submit a renewal application within 6 months of the expiration date of
the current certificate.
Providers who fail to maintain a current Fair Employment Practices Certificate will be
subject to the Network‘s Scope and Severity Process up to and including termination of
the contract.
Accreditation
The following organizations will satisfy site requirements for all programmatic, outpatient
and residential services covered by accreditation (attestation that the accreditation
covers all services is required):
The Joint Commission
Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic
Association (AOA)
Accreditation Association of Ambulatory Healthcare (AAAH)
Council on Accreditation (COA)
Commission on Accreditation of Rehabilitation Facilities (CARF)
National Committee for Quality Assurance (NCQA)
Pioneer Behavioral Health (the Agency‘s contracted Credentialing Verification
Organization, CVO)
Organizations accredited by one of the above mentioned bodies or holding a State of
Michigan licensure or certification where State of Michigan standards meet or exceed
accreditation standards, and wishing to supply traditional outpatient services must also
meet the following:
The medical director and clinical director (the person clinically responsible for the
program) successfully completes verification of selected credentialing elements;
All physicians associated with the organization successfully complete verification
of selected credentialing elements.
12
For evaluation standards for non-accredited facilities, please refer to Gateway‘s
credentialing policy.
Child Mental Health Professional credentialing
All providers who have staff providing services to children must have their staff
credentialed through Pioneer Behavioral Health as a Child Mental Health
Professional.
Providers must submit all credentialing information to Pioneer Behavioral Health
upon hiring.
Staff will be credentialed according to the requirements defined for the Child
Mental Health Professional.
Initial credentialing is done within 90 days of hire.
Pioneer maintains a database of all credentialed staff.
Staff must be re-credentialed every two years and must maintain 24 hours per
year of continuing education units.
Contracted Providers are responsible for the following:
Maintaining updated written policies and procedures which guide the
credentialing process for employment
Decisions on credentialing and re-credentialing of practitioners
A list of individuals who are credentialed and the type of credential
Maintaining files that include the documentation that supports the credential
including
 A dated resume
 Evidence of primary source verification
 Relevant education
 Relevant training including 24 hours per year of ongoing population
specific (SMI, SED, DD) in-service training and/or continued education
related to the provision of services, supports, treatment and UR/UM
activities
 License/certification/registration
 Current competence
 Documentation of certification to provide special assessments services or
processes (e.g., Child & Adolescent Functioning Assessment ScaleCAFAS)
For physicians:
 Professional and general liability insurance
 Reports from the National Practitioner Data Bank and Healthcare
 Integrity & Protection Data Bank
 Checking Medicaid exclusion status
Ensuring all health care professionals are credentialed at a minimum of every
two years.
13
All entities receiving Federal funds have an affirmative duty to check the program
exclusion status of individuals and entities prior to entering into employment or
contractual relationships, or run the risk of civil money penalties. All health care
providers must check relevant Federal internet websites
(http://www.epls.gov/epls/search.do. and
http://exclusions.oig.hhs.gov/search.aspx)
prior to hiring or contracting with individuals or entitles and periodically for the
participating/exclusion status of current employees and contractors.
All employees, contractors, and consultants hired to provide professional or
direct care services to Persons receiving mental health services must be in good
standing with the law (e.g. not a fugitive from justice, a convicted felon or an
illegal alien). Criminal background checks must be completed on potential
employees.
Annual criminal background checks must be performed on all employees and other
personnel who have regular contact with consumers on behalf of the applicant‘s
company in order to be considered for contracting with Gateway.
Model Payment System (MPS) – Title XIX
Purpose - To maximize Title XIX (Medicaid) reimbursement for Personal Care Services
provided to Medicaid eligible recipients in licensed residential settings and coordinate
benefits for consumers.
Title XIX is a Supplemental Income given to Providers for care of consumers who are
not receiving payment from a network for personal care or community living supports to
care for consumers (non-specialized residential consumers). The Provider must be
licensed and meet minimum requirements of the Department of Consumer and Industry
Services (DCIS). Provider must also have an agreement with the Gateway to process
Title XIX for eligible consumers.
Eligible Care Providers - Providers must be licensed and meet minimum requirements
of the Department of Consumer and Industry Services (DCIS) and Department of
Community Health (DCH) as defined and contained therein, Act 117, Public Acts of
1973, as amended and Act 218, Public Acts of 1979, as amended, for residential
settings such as: homes for the aged, adult foster care family home, adult foster care
small group home, adult foster care large group home, adult foster care congregate
facility, foster family home, foster family group home, and child caring institutions and
enrolled in the Model Payment System.
14
Medicaid (MA) Designated Case Manager: case manager must be either a Qualified
Mental Retardation Professional (QMRP) as defined in 42 CFR 483.430, or a Qualified
Mental Health Professional (QMHP) as defined in Michigan‘s Medicaid Mental Health
Clinic Provider Manual, Chapter III.
Personal Care Services: services provided in accordance with an individualized plan of
service that assist a recipient by hands-on assistance, guiding, directing, or prompting
of Personal Activities of Daily Living (PADL) in at least one of the following activities:
EATING/FEEDING: the process of getting food by any means from the
receptacle (plate, cup, glass) into the body. This item describes the process of
eating after food is placed in front of an individual;
TOILETING: the process of getting to and from the toilet room for elimination of
feces, and urine, transferring on and off the toilet, cleansing self after elimination,
and adjusting clothes;
BATHING: the process of washing the body or body parts, including getting to or
obtaining the bathing water and/or equipment, whether this is in bed, shower or
tub;
GROOMING: the activities associated with maintaining personal hygiene and
keeping one‘s appearance neat, including care of teeth, hair, nails, skin, etc;
DRESSING: the process of putting on, fastening and taking off all items of
clothing, braces and artificial limbs that are worn daily by the individual, including
obtaining and replacing the items from their storage area in the immediate
environment. Clothing refers to the clothing usually worn daily by the individual;
TRANSFERRING: the process of moving horizontally and/or vertically between
the bed, chair, wheelchair and/or stretcher;
AMBULATION: the process of moving about on foot or by means of a device with
wheels;
ASSISTANCE WITH SELF-ADMINISTERED MEDICATION: the process of
assisting the client with medications that are ordinarily self-administered when
ordered by the client‘s physician.
Process and Procedure
Upon placement of a non-specialized mental health recipient into a residential foster
care setting, the case manager shall insure that any need for personal care services are
identified in the consumer‘s plan and according to Medicaid (MA) standards. In addition,
the case manager shall take the required action(s) to further insure that payment(s) for
personal care services are issued, and all payment problems are resolved.
15
Consumer must have active Medicaid during the effective dates of service. Consumer
must need on-going personal care services to be Title XIX eligible. Personalized
services are provided in accordance with an individualized plan of service that assist a
recipient with hands-on assistance, guiding, directing, or promoting of personal
Activities of Daily Living in a least one of these activities: Eating/Feeding, Toileting,
Bathing, Grooming, Dressing, Transferring, Ambulation and Assistance with SelfAdministered Medication. Personal care tasks are not required to be performed each
day. However, in a monthly payment program, personal care services must be
continuous and on-going during that calendar month for payment.
Responsibility of the Case Manager
Case Manager should develop a Service Plan/Plan of Service when the recipient
is admitted to the foster care facility to establish Title XIX eligibility funding. The
Case Manager will complete an assessment form at the time of the initial
placement and annually thereafter. The Service Plan should be developed jointly
with the recipient and foster care provider using the DWCCMHA‘s form. Personal
Care Services must be ordered by a Case Manager and be approved by their
supervisor, to be eligible for payment. The Case Manager must complete a 3803
Form. The 3803 Form must be approved (signed by the supervisor). If the
supervisor is not available, the 3803 form may be signed by a Registered Nurse.
Approval must be completed within three (3) business days.
The Case Manager will submit the original 3803 form to the Title XIX Specialist at
Gateway within seven (7) days of placement.
The Case Manager must review and sign off on the provider log kept at the
provider site at least once each month to ensure that personal care services are
being delivered.
The Case Manager must re-evaluate the consumer within 365 days of the last
order date to determine if the consumer still requires Personal Care Services.
Provider should notify Case Manager and Title XIX Specialist within 24 hours
regarding any consumer who moves, becomes hospitalized, leaves home
permanently, or dies.
A new order/form is required when:
A recipient moves;
A recipient has never lived in a non-specialized residential setting;
A substantial change (clinically) has occurred;
Recipient transfers from DHS or another Community Health Services provider or
MCPN;
16
Title XIX eligibility has lapsed (3803 Form is expired) after 365 days or approval
of services has not been obtained within 15 days after order has been signed
and dated.
Instructions for completing the 3803 Form
Name:
Agency Number:
Move in Date:
Date of Birth:
Sex:
SSN#:
FIA:
Medicaid ID #:
Diagnosis:
Type of Guardianship:
County:
Placement facility:
Phone Number:
Address:
Medicaid Provider ID Number:
Global Assessment of:
End Date Reason:
Parent/Legal Guardian Name:
Treatment/training (PPB):
Objective:
Type of Facility:
Provide/Assist:
Guide/Direct:
Full legal name of consumer
Consumer‘s member number
Date consumer entered the home
Consumer‘s date of birth
Male or Female
Recipient‘s Social Security Number
FIA/DHS Case Number
ID number as it appears on the recipient‘s
Medicaid Card
Clinical diagnosis using ICD-9-CM
classification
Consumer‘s guardianship, if any
County of residence
Name and address where the recipient lives
Telephone number of the facility
Address of the facility
Provider ID
Recipient‘s GAF Score Functioning
Leave Blank
Consumer‘s Parent(s) or Legal Guardian
Type of treatment for the consumer (usually
Rehabilitation is stated for mental health)
Check one
Level of care of recipient
Check this column if the recipient is totally
dependent upon staff to perform the task for
him/her, or is partially dependent and needs
physical assistance, meaning ―hands on
service‖
Check this column if the recipient can perform
the task him/herself but requires verbal
direction in the form of prompts or reminders
When the Title XIX Specialist receives the 3803 Form from the Case Manager, the Title
XIX Specialist will enter the authorization into the AuthentiCare System. Once this
process is completed, the provider is able to bill monthly for the personal care services.
Provider of services must maintain a service log that documents specific days on which
personal care services were delivered consistent with the recipient‘s individual plan of
services.
17
Providers are required to use MI AuthentiCare. MI AuthentiCare is a paperless billing
system for Adult Foster care (AFC) providers. The system provides automated
electronic billing for facility services provided through the Department of Human
Services (DHS), formerly Family Independence Agency (FIA) and Community Mental
Health Service Program Boards (CMH). Providers do not bill Gateway.
Gateway consumers in an AFC home who are receiving services through one of the
Primary Providers (the eight partner agencies for the Gateway Network) must be
authorized by the Network. Therefore, if there are consumers who have been put on
Title XIX through FIA/DHS, they must be end dated from FIA/DHS and enrolled on the
AuthentiCare System through Mental Health (CMH).
Providers cannot bill through MI AuthentiCare before the end of the month. Providers
can only bill for services at the beginning of the next month for services in the previous
month, which is after services have been provided. Providers can bill within 370 days
from the date of service. The provider may call or use the website to bill for the client.
Providers will no longer receive the FIA 2353 invoice. The MI AuthentiCare system
takes the place of this form.
Providers will need their Identification (ID) Number and Pin Number when completing
their billing, as well as information on clients that they are billing for, such as the
Medicaid ID number and the dates that the consumer was in the AFC home.
If a client leaves the AFC home during the month, the provider should contact the case
manager. The case manager will contact the Title XIX Specialist to end date the client
from the Authenticare system.
If a provider bills for services that are not rendered, the provider will be responsible to
reimburse the Michigan Department of Community Health.
Provider Agreement
The FIA-1625 is a two-part form that must be completed by AFC providers prior to
enrollment. No authorization can take effect prior to the date of this agreement. The
agreement is in effect until there is a change of licensee or facility name in which case a
new agreement must be obtained. The provider sends the original to Gateway. Gateway
sends the form to the Medicaid Payment Division in Lansing for provider enrollment.
Once Gateway has been informed the provider has been enrolled, Gateway will contact
the provider with their enrollment number.
The FIA-AFC licensing system is computerized and provides a Data Base for linking
with the Model Payment System.
This data base is automatically updated weekly to reflect licensing changes. When an
AFC provider is enrolled, the licensing data is confirmed from the data base. However,
Termination of a license automatically end dates the license eligibility on the MPS.
18
Duplicate Payments of Title XIX Funds
Providers cannot receive payment for personal care services from Gateway while at the
same time receiving payment for personal care services under the Model Payment
System.
When this error occurs, the following steps should be taken:
Title XIX Specialist/ Case Manager will notify PCS LANSING immediately and identify
what happened in a written statement and includes pertinent information. This
statement should be forwarded to:
DCH, Bureau of Finance
P. O. Box 30668
Lansing, MI 48909-8168
Over Payment and Recoupment
The Network is responsible for correctly determining eligibility of payments of service
program needs and the amount of those payments. When an overpayment is
discovered, corrective action must be taken to prevent further overpayment and to
assure the overpayment is recouped.
Providers are responsible for correctly billing for personal care services which were
authorized and actually delivered.
Title XIX Specialist ends the authorization immediately through AuthentiCare and sends
an Overpayment Letter to Provider. If notified by DCH Program office that repayment
has not been made by provider, Title XIX Specialist will follow up with provider.
The Adult Foster Care Provider must write an explanation for overpayment and enclose
the repayment of funds. (Un-cashed warrant or personal check made out to STATE OF
MICHIGAN).
PROVIDER SANCTIONS
At the sole discretion of Gateway, action may be taken when there is evidence that a
Provider is out of compliance with the terms and conditions of the Agreement and/or
with other regulatory requirements or statutes.
The following is a list of the sanctions available to Gateway. They do not have to be
issued progressively. Depending upon the nature of the violation, an immediate
termination of the Agreement may be levied.
Corrective Action Plan: A letter identifying the specific violation(s) will be
presented to the Provider along with a request for the Provider to prepare a
written plan of correction (CAP).
19



The CAP must include a specific target date for meeting compliance,
details regarding actions to be taken to correct the deficiency and the
person responsible for assuring the correction is achieved.
The CAP must also include provisions for ongoing monitoring to assure
continued compliance.
Gateway will inform the Provider of the acceptance of the CAP, in full or in
part. Gateway may request the Provider make revisions to the CAP.
Suspension of Referrals: This action would be taken as the result of identified
health, safety, or well-being issues of consumers. The suspension may be made
for a specific Provider program that is not in compliance. A suspension of
referrals is generally taken along with a corrective action plan. Written notice to
the Provider will specifically identify the condition that resulted in the suspend
referral suspension, the required corrective action(s) and a target date.
Withholding of Funds: A Provider will be notified that payment will be withheld
along with the reason for the withholding. The Provider must meet the required
conditions for the release of the withheld funds. Failure to meet Medicaid
Provider Services standards and repeated failure to submit timely, related would
be an example of when this sanction may be used.
Removal of Consumer(s)
Termination of the Agreement
Immediate Termination or Suspension: At Gateway‘s sole discretion, any of
the following events shall/may result in the immediate termination or suspension
of the Agreement:
The withdrawal, expiration or non-renewal of Agency required
credentialing of Contracted Provider;
The bankruptcy or receivership of Contracted Provider, or an assignment
by Contracted Provider for the benefit of creditors;
The loss or limitation of Contracted Provider's liability insurance;
A reasonable determination by the Agency or Gateway that Contracted
Provider's continued management and delivery of the Covered Services
could result in harm to Persons;
The debarment or suspension of Contracted Provider from participation in
any governmental sponsored program, including, but not limited to,
Medicare or Medicaid;
The indictment or conviction of Contracted Provider for any crime;
Change of control of Contracted Provider to an entity not acceptable to the
Agency or Gateway; or
Disapproval of the Contracted Provider by the MDCH or any other
governmental entity, to the extent such approval is required in connection
with the funding for Covered Services delivered hereunder.
20
As per the Agreement, Contracted Provider shall provide immediate notice to the
Agency and Gateway, upon Contracted Provider's knowledge of any of the aforesaid
events.
21
Section III
Information Management/Claims Processing
Introduction
It is the policy of Gateway to manage its core operations including claims processing
per the contract standards of Detroit-Wayne County Community Mental Health Agency.
This information is to serve as a guide regarding claims processing and procedures.
Providers receive compensation for services rendered to Gateway consumers through the
submission of claims or encounter data depending on the terms of the provider contract.
Providers must be contracted with the Network to be eligible for reimbursement for
services rendered. Please refer to the Network Contracting Process.
For submission of claims for services that require prior authorization, providers must
contact Gateway to receive an authorization letter, which will include the
following:
The period of authorization (start date of authorization and ending/lapse date)
The service category or codes to be used in billing.
The number of units of services authorized
Claims Submission Methods
Based on the type of provider, claims are submitted in different fashions:
Residential Providers (Providers of Personal Care and Community Living Supports
in a residential setting) - Residential Providers submit claims for services
rendered utilizing a 3806 form. This can be done via a paper form or an
electronic version of the 3806.
Outpatient Provider Agencies - Agency providers can submit claims for services
utilizing the CMS-1500 form for authorized professional outpatient services.
Hospitals - Hospitals will submit claims for services rendered utilizing the CMS1500 form for authorized professional/physician services and the UB-04 (CMS-1450)
claim form for authorized hospital admissions.
Electronic Claims Submission
Providers with sufficient capacity and capabilities can submit claims through the use of a
HIPAA compliant electronic data file format called the ANSI ASC X12N 837 Format.
Residential providers can submit services electronically through the use of the 3806 DDE
(direct data entry) system.
The information required to complete electronic and paper claims is the same; however,
electronic claims may require providers to input information into different fields.
Software vendors typically provide instructions for entering the information.
22
For submission of claims using the ANSI ASC X12N 837 Format, please contact BayArenac Behavioral Health at 1-800-288-5309.
For submission of claims using the 3806 DDE form, please contact Gateway‘s Provider
Service Team at 313-262-5040.
Claims Processing
Providers must be issued a provider identification number specific to Gateway before
submission of claims for processing. Any provider who submits claims without including
their unique provider identification number will have those claims returned without being
processed for payment. Please note: the National Provider Identifier (NPI) number
currently does not replace the provider identification number assigned by Gateway,
however plans are underway to use the NPI number exclusively.
Providers must include the DWCCMHA member eligibility number on the claim in order
for the claim to be processed. If it is not correct or not included on the claim, the claims
edit process will issue a rejection and the claim will not process for payment.
For those services that require prior authorization, the complete authorization number
must be included on the claim in order for the claim to be processed. Inaccurate
authorization numbers will cause the claim to be rejected. It is the provider‘s
responsibility to obtain authorization for those services that require prior authorization
before services are delivered.
Coordination of Benefits (COB)
Providers are required through contract (or Letter of Agreement) to coordinate benefits
appropriately. Prior to submission of claims, providers must identify and bill
consumer‘s other sources of coverage for care as well as determining a consumer‘s
ability to pay. Gateway funds are the funds of last resort. Failure to coordinate
benefits appropriately is a violation of the contract and Medicaid guidelines.
The provider must make every attempt to seek reimbursement from other third party
payers before seeking payment from the network including exhausting all levels of
appeals with third party payers. Third parties must be billed timely.
All third party claims for coordination of benefits must be submitted on paper with the
Explanation of Benefits (EOB) from the other insurance company attached. An electronic
printout of the provider‘s data system is not acceptable for COB. No electronic billing is
accepted for COB. Claims received without the EOB are returned to the provider using
the send back letter indicating this requirement.
All COB claims are reviewed by a claims specialist to determine if additional payment
from the network is necessary.
23
If the provider was reimbursed by the third party equal to or exceeding the contracted
amount with the networks, there is no amount due to the provider, this includes copays and deductibles.
The provider may not hold a Medicaid eligible member liable for any costs, charges,
fees or other liabilities in the event that the network becomes insolvent, or payment is
not made by the State, Detroit-Wayne County Community Mental Health Agency or any
other entity.
The provider is required by contract to assist eligible consumers in applying for and
maintaining Medicaid coverage. Eligibility changes must be reported to the consumer‘s
case manager.
Link to the Medicaid Application can be found in the Addendum section of this manual.
ICD-9-CM Codes/Billing Codes
Procedure Codes: All claims must be Health Insurance Portability and Accountability
(HIPAA) compliant. Only procedure codes approved by the Michigan Department of
Community Health and in the contracted providers benefit array may be utilized. Any
code that requires a modifier must include such modification in order for the claim to
be processed.
Revenue Codes: Hospitals are paid on a per diem basis and must include the appropriate
revenue code according to the type of unit. (Refer to appropriate coding manual for
description of revenue codes.) MDCH code list is listed in the Addendums section of this
manual.
ICD-9-CM codes: The claim must include a primary diagnosis code that is listed on the
Michigan Department of Community Health‘s list of approved diagnosis code edits for
reimbursement. Codes submitted that are not on this list will cause the claim to reject for
invalid diagnosis code. This list is available in the Addendums Section of this manual.
Filing Limits/Forms
Providers are encouraged to submit claims as soon as the service has been provided.
Providers shall submit claims for Covered Services to Gateway in a manner and format
prescribed by Gateway, and claims must be submitted no more than ninety (90) days
after the date of service and no later than two (2) months after the end of the Agency
fiscal year, whichever is sooner. Payment for any claims not submitted within such time
period shall be denied, except under circumstances relating to good faith efforts to
coordinate benefits with other third party payors.
Corrections or additions to claims shall be accepted by Gateway only if made within
thirty (30) days from receipt of the initial claim.
24
Claims subject to third party reimbursement shall be submitted to Gateway within ninety
(90) days of Contracted Provider's receipt of third party reimbursement, but in no event
later than one year from the date of service.
Claims must be submitted to:
Bay Arenac Behavioral Health
Gateway Claims Dept.
P.O. Box 5559
Saginaw, MI 48603
Clean claims received by Gateway claims processing department will be processed
within 30 days of receipt.
Clean claim means a claim or an encounter submitted on a CMS-1500, CMS-1450
(UB-04) or 3806 claim form for Covered Services rendered by Contracted Provider with
descriptive service and Consumer information that:
Identifies the owner and facility that provided treatment or service including
matching identifying numbers, or any affiliation status
Identifies the Person with accurate identifiable information
Lists the date and place of service
Is a claim for Covered Services for an eligible Consumer
If necessary, substantiates the Medical Necessity and appropriateness of the
service provided
Includes any applicable prior authorization number
Identify services rendered using proper procedure and diagnosis codes
Include additional information when required by Gateway
Is certified by the Contracted Provider to be true, accurate, and prepared with the
knowledge and consent of the Contracted Provider.
Completion of Paper Claim Forms:
Be sure the dates are within the appropriate boxes on the form
Use only black ink
Handwritten claims must be legible
Keep a copy for your records
Forms that do not meet the above requirements cannot be processed and will be
returned to the provider unprocessed.
For completion of the 3806 form:
Provider Number: Enter the provider identification number assigned by
Gateway.
Provider Name: Enter the provider name of the facility where the consumer is
located.
Provider Address: Enter the address of the facility.
Bill Through: Enter the month and year of the billing period.
25
Provider Phone: Enter the provider phone number.
Member #: Enter the member identification number.
Name (Last, First): Enter the member‘s last name and the member‘s first
name.
Authorization #: Enter the authorization number as provided on the Letter of
Authorization.
Primary ICD9: Enter the primary ICD9 diagnosis of the member.
Secondary ICD9: Enter the secondary ICD9 diagnosis of the member if
applicable.
Service Code: Enter the HCPCS, CPT or Revenue code being billed for
services rendered for the member as agreed in the provider‘s contract.
Days In.: Enter the number of days the consumer is in the facility.
Days Absent: Enter the number of days the consumer was not in the
facility.
Total Days: Add together the days in column and the days absent
column.
Per Diem x Days In: Enter the amount derived from this calculation.
Payment is only made for actual days of service, not vacant bed days.
Net Bill: Is the total amount billed minus any coordination of benefit payments
to the provider.
1 through 31: Place a ―V‖ on the box for circumstances/dates when the
member is in residence.
Signature of the Provider: A representative of the provider organization must
sign this form.
Date: Enter the date this form was signed.
Mandatory: All items are required for all claims. If the item is left blank, the claim
cannot be processed.
Summary for completion of a CMS 1500 (HCFA 1500):
Line #1
Mark appropriate box, Medicare, Medicaid, etc.
Line #1a
Insured‘s I.D. number (consumer‘s unique member ID on the
authorization)
Line #2
Patient‘s name (Member Name)
Line #3
Patient‘s date of birth and sex
Line #5
Patient‘s address
Line #6
Patient‘s relationship to insured
Line #9
Complete this section if there is another insurance company
Line #10
Patient‘s condition related to
Line #12 & 13
Signature on file and current date
Line #21
Diagnosis – ICD-9-CM code
Line #24a
Dates of service
Line #24b
Place of service
Line #24d
Billing codes
Line #24f
Dollar amount of charges
Line #24g
Number of days/units being claimed
26
Line #25
Line #28
Line #29
Line #30
Line #31
Line #32
Line #32a
Line #33
Federal Tax ID Number (SSN or EIN)
Total charge
Amount paid (Use if another insurance company or the
company has made partial payment or there is an ability to
pay. EOB from other insurance must accompany claim upon
submission for payment
Balance due
Your signature and date
Name and address where services were rendered
NPI number of #32
Billing name, address and provider number assigned by
Gateway
NPI number of #33
Line #33a
.
If the adjudication process determines that a paper claim is not clean, the claim will be
returned with a form indicating the area or areas needing to be addressed.
Provider must correct claim and resubmit for payment
Claim is processed by Gateway claims processing department.
Explanation of Benefits/Remittance Advise
Providers will receive an Explanation of Benefits (EOB) that details every claim
submitted unless the claim was returned for not meeting minimum criteria for claims
processing. The EOB will accompany the provider‘s payment.
The following are claims edits currently part of the claims processing procedure:
ANR - Authorization Not Required - the code billed has been paid without an
authorization
CNC - Coverage Not Current - referring to the members eligibility with Gateway &
indicating that the member was or is enrolled, but not on this date of service
CNE - Client Not Enrolled - indicates that the member became eligible after the date of
service billed
COB - Third Party Primary - the payment is based on another insurance which is
primary
DBP - Denied, Bill to Primary- a third party carrier must be billed prior to payment
consideration
DPC - Denied by Primary Carrier - EOB received with claim indicates primary carrier
denied of which we also will deny
DS - Duplicate Claim - denied due to previously processed claim to same vendor,
date of service, and service code category
INV - Invalid Client ID - the member number billed is not found on the system
PCR - Paid at Contracted Rate - the procedure billed was reimbursed per the rate
indicated in the providers contract
LN - Too Long from Service to Claim - the date of service billed is beyond the
parameters set by the provider‘s contract for timely billing
27
MAX - Billed Max Units - procedure is set up on system to pay a designated number
of units for a date of service and claim was received billing more than this
amount
PA - Paid as Claimed – claim paid as billed
PAR - Prior Authorization Required - authorization for the service billed must be
obtained
PLA - Paid Less than Claimed - paid at contracted amount which is less than billed
amount
QAL - Quantity Over Approved Limit - units are already used for the authorizationnot enough units in the authorization to cover services billed
SNB - Service Not in Benefit Plan - the code billed does not appear in the provider‘s
contract of billable services
VOID - Void Claim - previously paid claim line has been voided and money is taken
back
Resubmitting a claim
Providers should only resubmit a claim for the following reasons:
The paper claim was returned with a Claim Send Back Form describing claim
defects that must be corrected
The electronic claim file was not processed
The claim was denied
Providers should not submit claims that have already been processed and paid
even if the claim did not pay as intended or authorized. These claims will need to be
reviewed by Provider Service for possible reconciliation.
Claims Appeal Process
For claims denied based on processing guidelines (denials that do not involve medical
necessity criteria) the provider must submit a request in writing to the Provider Service Team
(providerservice@gchi.org) within 60 days of the rejection. Provider must submit all
necessary information required to assist in the review of the appeal. Provider Service
will review the appeal and respond to the provider in writing within 30 days of receiving
the request for appeal. If the decision is to process the claim, the provider has 30 days
to submit the claim to Provider Service for processing.
Please note: this does not apply to claims that were rejected for not being a "clean
claim" such as rejections for invalid member ID or service not in benefit plan. When the
provider has all the necessary information to submit a clean claim, the Provider can
resubmit.
Fraud and Abuse
Gateway is committed to the prevention of fraud and abuse. Examples include:
Billing for nonexistent or unnecessary medical services
Billing for professional services rendered by personnel lacking appropriate
credentials to provide the service
28
Double Billing - billing Medicaid and another insurance company for the same
procedure
It is Gateway‘s policy to vigorously enforce all Federal and State statutes related to the
filing of false claims. If Gateway has reason to believe a Provider may have committed
fraud or abuse, the Quality Improvement or Compliance department, or designee, will
conduct a thorough review including reviewing claim forms, medical records, progress
notes, staffing levels and attendance records and other documents as necessary. The
absence of substantive documentation of the delivery of billed services will be construed
as presumptive evidence that such services were not delivered and will be considered
as evidence of possible fraud or abuse or violation of the Medicaid False Claims Act.
Gateway is required to report to the appropriate agencies if there is suspected fraud or
abuse. If the fraud and abuse allegation is substantiated, Gateway will require
repayment of involved funds and will review the Provider for further contract sanctions up
to and including termination.
29
Section IV
Financial Management
Introduction
Gateway is committed to maintaining accurate and complete financial information
relative to payment for services provided to eligible Consumers.
Ability to Pay
It is the policy of Gateway to monitor contract providers regarding ability to pay
determination parameters as prescribed within the Michigan Mental Health Code and, as
applicable, Medicaid regulations. Providers are to establish guidance and implement
protocol for Provider‘s staff and subcontractors for the collection of ability to pay
information for uninsured and under insured Consumers.
Gateway has adopted the following, as allowable under applicable Federal laws,
regulations, and waivers, as their operational oversight procedures regarding
compliance with the requirements of Chapter 8 of Michigan‘s Mental Health Code
regarding evaluating the ability to pay of consumers who are uninsured or under
insured:
The fee determination/ability to pay process should be completed by the
Gateway provider appointed to perform that role during the first appointment
or as soon as practical after the start of services.
For a consumer who receives inpatient services on a voluntary basis, the
hospital shall perform its statutory duty to determine the responsible parties‘
insurance coverage and ability to pay as soon as practical after the individual is
admitted.
Consumer fees shall be reassessed annually or at re-entry, which ever is first
or if there is any substantial change in the consumer‘s financial status.
Providers shall charge responsible parties for that portion of the financial
liability that is not met by insurance coverage.
Providers shall not impose charges in excess of ability to pay or impose
an undue financial burden on the individual or the individual‘s family
members.
An individual shall not be denied services because of the inability of responsible
party to pay for services.
As stated in the Mental Health Code, ―If an individual is covered, in part or in
whole, under any type of insurance coverage, private or public, for services
provided directly by or by contract with the department or a community
mental health services program, the benefits from that insurance coverage
are considered to be available to pay the individual financial liability,
notwithstanding that the insurance contract was entered into by a person
other than the individual or notwithstanding that the insurance coverage
was paid for by a person other than the individual.‖
30
If the responsible party believes the figures used to determine their ability to pay are not
appropriate to their current income status or do not appropriately reflect their ability to
pay, they may request a new determination of ability to pay.
The responsible party has a right, by means of an administrative hearing, to contest
an ability to pay determination. There must be notification to D-WCCMHA or the
Michigan Department of Community Health (MDCH) on the appropriate MDCH form.
If the responsible party willfully fails to provide relevant insurance coverage information
or if the responsible party willfully fails to apply for affordable and available insurance
benefits that cover the cost of services provided to the individual by Gateway with
funds received from MDCH or D-WCCMHA, the responsible party‘s ability to pay shall
be determined to include the amount of insurance benefits that would be available. If
the amount of insurance benefits is not known in a case described in this section, the
responsible party‘s ability to pay shall be determined to be the full costs of services.
After determination of the responsible party‘s ability to pay, providers are required to
deduct the ability to pay amount determined above from the amount billed to Gateway.
Claims Verification
It is the policy of Gateway that all providers submit claims for reimbursement in accordance
with all federal, state and local standards.
All reimbursed services are subject to review for conformity and accepted medical
practice and coverage limitations. Post-payment reviews of paid claims may be
conducted to assure that the services, the rendering provider network and setting, were
appropriate and comply with the policy. Post-payment review also verifies that services
were billed appropriately (e.g., correct procedure codes, modifiers, quantities, etc. and that
third party resources were utilized to the fullest extent available (i.e. Coordination of
Benefit and Ability to Pay).
Examples of parameters for claims verification methodology to be used by Gateway
include, but are not limited to:
Claims verification of services delivered to persons with serious mental illness
including both adults and children.
Claims verification of services representative of array of covered services provided
by the agency under review.
Sample selection based on information from the claims system (Note: at times, the
Agency may choose the sample based on their concerns as the Agency retains
oversight of the complete process).
Claims verification of samples up to 100% of claims/services rendered by any
provider for which such verification is in the sole discretion of Gateway determined
to be appropriate.
A verification process that includes on-site reviews and interviews with members as
deemed appropriate by Gateway.
31
Advance notice (optimally two (2) days) to the provider receiving the audit or
verification process.
Confirmation of the following through an on-site record review based on
claims/invoices/encounter data submitted:
 Services claimed are listed in Chapter III of the Medicaid Provider Manual
 Services claimed were identified in the Person-Centered Plan
 Services claimed were documented as provided within the member‘s
record
 Prerequisite services were provided when required
 Dates of service on submitted documentation match dates of service in onsite record
 Services were provided by qualified staff with appropriate signature
Notification to the provider about deficiencies found and what follow up is
required including a Plan of Action or Plan of Correction.
Notification to the Agency of any Plans of Correction.
Set time frames for follow-up visits.
Utilization of the Network‘s Scope and Severity Protocol for assessing provider
performance
deficiencies
and
imposing
remediation
sanctions.
Remedies/sanctions may include, but are not limited to:
 A written Plan of Action or Plan of Correction
 A ban on new referrals
 Holding of claims during an investigation period
 Reimbursement of funds
 Reporting to appropriate licensing/law enforcement agencies
 Termination of contract
The False Claims Act applies when a company or person:
Knowingly presents (or causes to be presented) to the Federal Government a
false or fraudulent claim for payment,
Knowingly uses (or causes to be used) a false record or statement to get a claim
paid by the Federal Government,
Conspires with others to get a false or fraudulent claim paid by the Federal
Government,
Knowingly uses (or causes to be used) a false record or statement to conceal,
avoid, or decrease an obligation to pay or transmit money or property to the
Federal Government.
The government is no longer required to prove that a physician or another claimant
had a specific intent to violate the law.
If Gateway has reason to believe a provider may have committed fraud or abuse, the
Compliance Department, or a designee, will conduct a thorough review of claim
forms, medical records, progress notes, staffing levels, attendance records and other
documents as necessary.
32
The absence of documentation of the delivery of billed services will be considered
evidence that such services were not delivered and will be considered as evidence of
possible fraud or abuse or violation of the Medicaid False Claims Act.
If the fraud and abuse allegation is substantiated, Gateway will require repayment of
involved funds and will review the contract and implement contract sanctions up to and
including termination of the contract(s)
33
Section V
Clinical Services
Introduction
Gateway is responsible for managing a wide array of clinical services. Gateway staff
manages inpatient psychiatric hospitalizations and partial hospitalizations, residential
placement, ACT, Skill Building and Home-based services.
Emergency Procedures
Gateway emergency services are available 24 hour per day, 365 days per year
by calling (313) 262–5050 or (800) 973-4283. The phone is answered by Gateway‘s
Customer Services Department who can assist you in a crisis/emergency situation
either with information and referral and/or direct transfer to the delegated crisis
screening staff. The policy and procedures are as follows:
All members requiring screening for inpatient hospitalization will have this
service available face-to-face, as needed, within the 30-minute, 30-mile contract
standard. Appropriately trained staff shall complete all such screenings and
all dispositions shall be made within three (3) hours of the referral.
Gateway strives to ensure the health and safety of the people and communities
we serve, ensure continuity of clinical care for the people we serve, and
meet contractual performance standards with the Detroit-Wayne County
Community Mental Health Agency.
Residential Emergency Contact Procedures
Contact Gateway at 313-262-5050 or 1-800=973-4283 24 hours per day, 365
days per year. All emergencies are communicated to Gateway and the primary
provider Case Manager.
A supervisor should always be available. If the situation is emergent and you are not
able to reach an appropriate provider staff, contact Gateway at 800-973-4283 or 313262-5050.
In cases of an immediate, life-threatening medical or psychiatric concern, the
Direct Care Staff should first employ all lifesaving measures and/or call the Fire
Department, Police Department, Ambulance (e.g. call 911), or transport the person to
the nearest Emergency Room (depending on the specific circumstances). The Direct
Care staff should then notify the appropriate primary provider case manager and
Gateway.
For psychiatric, behavioral and non-medical emergencies (such as violation of
behavioral agreement or failure to respond appropriately to staff on duty) it is the goal of
Gateway Community Health to keep the individual stable and in the community as much
as possible.
34
Towards this goal, we request the Provider and/or the Direct Care Staff should, using
their best judgment of the situation, to first contact the responsible clinical staff using the
directions above.
Clearly state:
 Your name and name of provider/home
 Gateway Member‘s name
 The nature of the concern (briefly)
The staff directly involved with the case may be referred to a clinical care coordinator to
receive recommendations on how to best deal with the situation and may, in some
cases, be able to avoid the need for removing the individual from the setting. If there is a
need for a face to face psychiatric screening, a referral will be made to the appropriate
screening agency; Detroit Receiving Hospital Crisis Center for adults and Children‘s
Hospital of Detroit for children.
For medical matters (such as resident illness, physical symptoms/complaints) the
resident should be taken to the hospital. For medication refusal, complete an Incident
Report and follow the Detroit-Wayne County Community Mental Health Agency
guidelines for Incident Reports and deliver them as instructed (see below).
Incident Reports: All Incident Reports are to be completed and faxed, within 24 hours,
to the DWCCMHA ORR at (313) 833-2043, the QI department at (313) 263-2453 or
(313) 263-2513, and the responsible CMHC.
Evacuations: In situations resulting in the need to evacuate the living site, it is expected
that each provider has emergency plans in place. Once the situation has been stabilized
and all residents are safely accounted for, notice should be given to Gateway
Community Health using the Incident Report process described above. Any emergency
contact with Gateway should be referred to 800-973-4283 or 313-262-5050.
Person Centered Planning
It is the policy of Gateway that Person Centered Planning techniques and philosophy
will be utilized when developing Individual Plans of Service for services and supports
offered by Network contracted providers.
Person Centered Planning is a highly individualized process designed to respond to
the expressed needs/desires of the person. Each person has strengths and the
ability to express preference and to make choices. The person‘s choices and
preferences shall always be honored and considered, if not always granted. Each
person has gifts and contributions to offer to the community, and has the ability to
choose how supports, services and/or treatment may help them utilize their gifts
and make contributions to community life. Person-Centered Planning processes
maximize independence, create community connections, and work towards
achieving the person‘s dreams, goals and desires. A person‘s cultural background
shall be recognized and valued in the decision- making process.
35
The Person Centered Plan is that person‘s vision of what he/she would like to be and
do. The plan is not static, but rather it changes as new opportunities and obstacles
arise. It contains the listing of services and supports agreed upon during the PersonCentered Planning process. It describes the goals, the supports needed specific to
amount, scope, frequency and duration, who is responsible for working on the goal and
the target date for goal completion.
Capacity Building - focuses on the person‘s gifts, talents, and skills rather than deficits. It
builds upon the person‘s capacities and affords opportunities which will reasonably
encourage the person to engage in activities that promote a sense of belonging in the
community.
Person Centered Focus - the focus is continually on the person for whom the plan is being
developed, and not on plugging the person into available slots in a program. The person‘s
choices and preferences must be honored.
Network Building – the process brings together people who care about the person, and are
committed to helping the person articulate their vision of a desirable future. They learn
together and invent new courses of action to make the vision reality.
Outcome Based – the plan focuses on increasing any or all of the following experiences
which are valued by the person:
1. Growing in relationships or having friends.
2. Contributing or performing functional/meaningful activities.
3. Sharing ordinary places or being part of their own community.
4. Gaining respect or having a valued role which expresses their gifts and
talents.
Community Accountability – the plan will assure adequate supports when there are
issues of health and safety, while respecting the person‘s dignity as a fully participating
member of the community.
Standards
Persons have the right (regardless of age or level of care setting) to direct the
planning for support services and/or treatment, and shall be informed of this right
at admission and again during the process used to plan their care.
Prior to the development of the Individual Plan of Service, the person will be
allowed to express a preference for which individuals to involve in the preplanning and planning process. This may include involvement of specific family
members, advocates, or other professional staff who are supporters of the
person. Plans of service shall be developed in a manner that promotes the
person‘s strengths, needs, abilities, and preferences.
For people participating in programs where a ―brief therapy‖ protocol is
employed, these standards still apply and the person will be given the opportunity
to involve family or other community persons, as they may desire.
Services must be delivered in a manner that is flexible and accommodating to the
needs of the person and their support network, particularly in regard to meeting
times.
36
Person-Centered Plans shall use adequate supports to safeguard persons in the
community, while respecting their dignity.
Whenever the person‘s Person-Centered Plan would cause them to be at risk for
harm to self or others, issues of health and safety shall take priority.
Complaints made regarding the failure to use a Person-Centered Planning
approach shall be accommodated by offering the right to appeal. If the person is
not satisfied with the results of the appeal, complaints shall be investigated by
the Office of Recipient Rights.
The appropriate staff will assess the person‘s degree of satisfaction with their
ability to participate in the treatment planning process through such tools as
satisfaction questionnaires or other feedback methods.
Person-Centered Planning (PCP) Practice Guidelines - Essential Quality Elements
Person-Centered Planning is a process in which the person is provided with
opportunities to reconvene any or all of the planning processes whenever he/she
wants or needs.
The process encourages strengthening and developing natural supports by inviting
family, friends and allies to participate in the planning meeting(s) to assist the
person with his/her dreams, goals and desires.
The development of natural supports shall be viewed as an equal responsibility of the
supports coordinating agency and the person. The supports coordinating agency, in
partnership with the person, is expected to develop, initiate, strengthen and maintain
community connections and friendships through the Person-Centered process.
The person is provided with the options of choosing external independent facilitation
of his/her meeting(s) as part of the pre-planning process, unless the person is
receiving short-term outpatient therapy only or medication only.
Before a Person-Centered Planning meeting is initiated, a pre-planning meeting occurs.
In pre-planning, the person chooses:
Dreams, goals, desires and any topic about which he/she would like to talk;
Topics he/she does not want discussed at the meeting;
Who to invite;
Where and when the meeting will be held;
Who will facilitate; and,
Who will record;
All potential support and/or treatment options (array of mental health services
including Medicaid-Covered Services and Alternative Services and Mental Health
Code-required services) to meet the expressed needs and desires of the person
are identified and discussed.
Health and safety needs are identified in partnership with the person. The plan
coordinates and integrates services with primary health care.
The person is provided with the opportunity to develop a crisis plan.
Each Individual Plan of Service must contain the date the service is to begin, the
specified amount, scope, frequency, duration and who will provide each authorized
service.
Alternative services are discussed.
37
The person has ongoing opportunities to express his/her needs and desires,
preferences, and to make choices. This includes:
Accommodations for communication, with choices and options clearly explained,
shall be made.
To the extent possible, the person shall be given the opportunity for
experiencing the options available prior to making choice/decision. This is
particularly critical for persons who have limited life experiences in the
community with respect to housing, work or other domains.
Persons who have court-appointed legal guardians shall participate in PersonCentered Planning and make decisions that are not delegated to the
guardianship papers from the court.
Persons are provided with ongoing opportunities to provide feedback on how they
feel about the service, support and/or treatment they are receiving, and their
progress toward attaining valued outcomes. Information is collected and changes
are made in response to the person‘s feedback.
Each person is provided with a copy of his/her Individual Plan of Service within 15
business days after the meeting.
When a person is in an urgent/emergent situation, the goal is to get the person‘s
crisis situation stabilized. Following stabilization, the person and supports
coordinating agency will explore further needs for assistance and if required,
proceed to a more in- depth planning process.
The Individual Plan of Service can be redone or amended prior to the annual date
due to significant change(s) or to meet the wishes of the person.
The person must be notified of their right to appeal/dispute the recommendations in
the PCP at the time of the PCP meeting. Such notification shall be documented
in the medical record.
Staff engaged in completing PCPs shall have evidence of ongoing training in PersonCentered Planning available in their personnel records.
Family-Centered Services are required for all children, and the following criteria must
be met:
Service delivery shall concentrate on the child as a member of the family, with
the wants and needs of the child and family integral to the plan developed.
Parents and family members of minors shall participate in the Person-Centered
Planning process unless:
The minor is 14 years of age or older and has requested services without the
knowledge or consent of parent, guardian or person in loco parentis
within the restrictions stated in the Mental Health Code;
The minor is emancipated; or
The inclusion of the parent(s) or significant family members would
constitute a substantial risk of physical or emotional harm to the person or
substantial disruption of the planning process as stated in the Mental
Health Code. Justification of the exclusion of parents shall be documented
in the clinical record.
38
Crisis Planning
It is the policy of Gateway that those Persons receiving services shall be offered an
opportunity to work with their treatment team to develop a crisis plan which could be
implemented when needed.
The purpose is to establish guidelines for clinical staff in utilizing the Crisis Plan as part
of the Person-Centered Planning Process in the development and implementation of an
Individualized Plan of Service and to assist consumers in contingency planning for crisis
situations, this may occur due to stress or decomposition.
A Crisis Plan is a plan of action to be implemented in the event of a medical or psychiatric
emergency. This plan is also a plan of prevention. Although a Crisis Plan is not
mandatory, the offer to complete a Crisis Plan is required by the Michigan Department of
Community Health (MDCH) and the Detroit-Wayne County Community Mental Health
Agency (DWCCMHA). A Crisis Plan is a part of the Person-Centered Planning
Process.
An emergency situation is a situation wherein the individual can reasonably be
expected, in the near future, to physically injure himself, herself, or another person; is
unable to attend to food, clothing, shelter or basic physical activities that may lead to
future harm; or the individual‘s judgment is impaired leading to the inability to
understand the need for treatment resulting in physical harm to self or others.
Contractors/subcontractors contracted with Gateway shall have a policy and procedure
regarding Crisis Planning. Consumers shall receive information regarding the
development of a crisis plan. Contractors/subcontractors contracted with Gateway shall
offer individuals receiving mental health services the opportunity to develop a crisis plan
whenever necessary and minimally as a part of the Person-Centered Planning Process.
Consumers shall make the decision to develop a crisis plan or decline developing such a
plan.
The Crisis Plan will include all of the following elements:
Those symptoms that would indicate to others that they need to take action in
the consumer‘s behalf.
How the consumer has handled this crisis in the past to help them feel safe,
healthy, and have a better quality of life.
Medications the consumer is currently taking, those that might help in a crisis
and those that should be avoided.
Treatments that the consumer prefers and those that should be avoided.
Actions that others can take that would be helpful in the crisis.
Actions by others that should be avoided during the crisis.
Past and present supports available to the person.
Consumer should have input into the handling and preventing of the crisis
situation.
39
Services and supports must be based upon health and safety needs, as well
as personal preference.
Health and safety of someone must always be considered and protected.
A Crisis Plan shall not take the place of a Safety Contract.
Who the consumer would want to take this action.
The Crisis Plan shall be reviewed and revised as necessary but minimally on
an annual basis.
Advanced Directives
Gateway ensures the right of their members to issue advance directives. Network
providers who provide 24-hour care will seek out these directives from the members
and offer referral information on ways members can issue these directives. Providers will
have policies in place that outline their implementation of advance directives.
Advance Directive is a legal document allowing a person to give directions about future
medical care or to designate another person(s) to make medical decisions if he or she
should lose decision-making capability. Advance directives may include living wills,
durable powers of attorney, or similar documents describing the preferences of the
member.
Providers of services will have available information and referral to appropriate sources
to assist those members who wish to initiate an advance directive.
During the intake process providers will, whenever possible, ask the member at intake if
they have an Advance Directive in place. Members who are dying will be counseled
during treatment about advance directives. Particular attention will be paid to advance
directives in developing pain treatment or pain management plans.
A copy of the Advance Directive will be kept in the clinical record, and any cases of dying
individuals that are transferred to another provider will include the directive in the
transferred paperwork. The issue of advance directives must be addressed in the personcentered plan when the plan includes pain treatment or pain management. Information
and referral to an appropriate source will be made available to those members inquiring
about issuing an advance directive.
This right extends to all adults or their designated decision-maker and is not limited to
those with a diagnosed terminal illness.
Network providers including those in 24-hour care settings will have a policy in place for
making decisions about withholding resuscitative services, or forgoing or withdrawing lifesustaining treatment which is based on the member‘s advanced directive. The policy will
identify the service provider‘s position on initiating or removing life-sustaining treatment.
40
Those providers whose policy is never to withhold resuscitation will inform the member
and/or their families of this policy.
Gateway Community Health Provider contracts will reflect the requirement of advance
directives where necessary.
Coordination of Care
It is the policy of Gateway that community mental health services shall be coordinated
with primary health care services, Medicaid Health Plans (MHPs), Substance Abuse
Coordinating Agencies, Individual Practitioners, Public Health Agencies and other
General Health Care Providers, utilizing the Person-Centered Planning (PCP)
process. This is a Network policy that applies to Gateway and their Contracted Service
Providers.
Gateway and their contracted providers shall meet or exceed the following:
Ensure coordination of care utilizing the PCP process, which clearly defines the
services and supports needed to achieve individualized goals.
Ensure the Person-Centered Planning Process clearly defines respective
responsibilities and health–related services when persons are jointly served.
Ensure full access to complaint/grievance/appeal processes, which enforce each
Person‘s IPOS/PCP rights.
Ensure adherence to this policy, including development, implementation and
monitoring of any policies and procedures be carried out with competent regard for
cultural, ethnic, gender and community values, and sensitivity for cultural
diversity.
Develop internal procedures that describe the step-by-step process of
Coordination of Care with Primary Health Care Providers and Medicaid Health
Plans.
Ensure the development, implementation, and monitoring of procedures to
coordinate care with substance abuse contractors (individual practitioners, public
agencies, and/or their designees) for Persons who are receiving ongoing
services and supports.
Ensure referral to the appropriate community resources when services requested
by the Person are not available on site.
Provide information to Persons receiving services, their guardians and parents of
minor recipients about the availability of family planning and health information.
41
This information shall include a statement that receiving mental health services
does not in any way depend upon requesting family planning services or health
information services.
Maintain updated information regarding licensure, controlled substance and Drug
Enforcement Administration registration information for physicians.
Ensure procedures are developed and implemented for notifying the Medicaid
Health Plan, consulting with practitioners prior to prescribing medication, and
sharing complete and updated medication records.
Receive referrals from Medicaid Health Plans for person‘s under the age of 21, as
a result of the Early Periodic Screening Diagnostic and Treatment assessment
Psychiatric Consultations on a Medical Floor
Gateway reimburses for psychiatric consultations on a medical floor for an eligible
Gateway Medicaid member per the requirements of the Detroit-Wayne County Community
Mental Health Agency contract.
The physician must be appropriately credentialed through the hospital‘s credentialing
process where services are provided.
Gateway will allow for one psychiatric consultation and one follow up consultation without
requiring prior authorization. Services after these initial sessions are to be preauthorized
by Gateway.
Covered Codes – Gateway is responsible for payment of the following codes: 9925199260 and 90862 in accordance with Medicaid Standards and Medicaid Fee Screens.
Contracting process may take place after services have been rendered to consumers
as this service may require an immediate psychiatric consult to determine mental status.
The Physician must still meet contracting requirements before reimbursement can be
made. Upon receipt of the required information, Gateway will determine if the
physician has been disbarred from participating in any Medicaid programs.
Physicians are issued an agreement to sign. This agreement must be in place before
payment to the physician can be made. Upon completion of the contracting process,
physician will be issued a provider number which is needed to bill for services. The
physician will be sent a copy of the agreement.
Claims processing - Physician or designee will be educated on submission of a HCFA
1500 form to the claims processing department. Clean claims will be paid in accordance
with contract standards and within 45 days of receipt of the claim. Claims should be
submitted within 60 days from the date of service and in accordance with Medicaid
standards.
42
Targeted Case Management
Providers of Targeted Case Management must demonstrate the capacity to provide
all core requirements specified below and have sufficient number of staff to meet the
needs of the target population.
Case management services are to be delivered in accordance with the requirements of
Chapter Three Section 13 of the Michigan Department of Community Health Medicaid
Provider Manual.
The determination of the need for targeted case management services must occur at the
completion of the intake process and through the person-centered planning process for
consumers receiving services and supports. Justification as to whether case
management is needed must be documented in the consumer‘s record with
alternative recommendations when appropriate.
Targeted case management is a covered service that assists beneficiaries to design and
implement strategies for obtaining services and supports that are goal-oriented and
individualized. Services include assessment, planning, linkage advocacy, coordination
and monitoring to assist beneficiaries in gaining access to needed health and dental
services, financial assistance, housing, employment, education, social services and other
services and natural supports developed through the person-centered planning process.
Targeted case management is provided in a responsive, coordinated, effective and
efficient manner focusing on process and outcomes.
A primary case manager must be a qualified mental health or mental retardation
professional (QMHP or QMRP); or if the case manager has only a bachelor‘s degree but
without the specialized training or experience they must be supervised by a QMHP or
QMRP who does possess the training or experience. Services to a child with serious
emotional disturbance must be provided by a QMHP who is also a child mental health
professional. Services to children with developmental disabilities must be provided by a
QMRP.
Targeted Case Management services must be available for all children with serious
emotional disturbance, adults with serious mental illness, persons with a developmental
disability and those with co-occurring substance use disorders who have multiple
service needs, have a high level of vulnerability, require access to a continuum of mental
health services and/or are unable to independently access and sustain involvement with
needed services.
Core Requirements
Assuring that the Person-Centered Planning process takes place and that it
results in the individual plan of service.
Assuring that the plan of service identifies what services and supports will be
provided, who will provide them, and how the Case Manager will monitor (i.e.,
interval of face-to-face contacts) the services and supports identified under
each goal and objective.
43
Overseeing implementation of the individual plan of service, including
supporting the consumer‘s dreams, goals, and desires for optimizing
independence; promoting recovery; and assisting in the development and
maintenance of natural supports.
Assuring the participation of the consumer on an ongoing basis in discussions
of his plans, goals, and status.
Identifying and addressing gaps in service provision.
Coordinating the consumer‘s services and supports with all providers, making
referrals, and advocating for the consumer.
Assisting the consumer to access programs that provide financial, medical, and
other assistance such as Home Help and Transportation services.
Assuring coordination with the consumer‘s primary and other health care
providers to assure continuity of care.
Coordinating and assisting the consumer in crisis intervention and discharge
planning, including community supports after hospitalization.
Facilitating the transition (e.g., from inpatient to community services, school to
work, dependent to independent living) process, including arrangements for
follow-up services.
Assisting beneficiaries with crisis planning.
Identifying the process for after-hours contact.
Assessment: The provider must have the capacity to perform an initial written
comprehensive assessment addressing the consumer‘s needs/wants, barriers to
needs/wants, supports to address barriers, and health and welfare issues.
Assessments must be updated when there is significant change in the
condition or circumstances of the consumer. The individual plan of services
must also reflect such changes.
Documentation: The consumer‘s record must contain sufficient information to
document the provision of case management, including the nature of the
service, the date, and the location of contacts between the Case Manager
and the consumer, including whether the contacts were face-to-face. The
frequency of face-to-face contacts must be dependent on the intensity of the
consumer‘s needs. The Case Manager must review services at intervals
defined in the individual plan of service. The plan shall be kept current and
modified when indicated (reflecting the intensity of the consumer‘s health and
welfare needs). A consumer or his/her guardian or authorized representative
may request and review the plan at any time. A formal review of the plan shall
not occur less often than annually to review progress toward goals and
objectives and to assess consumer satisfaction.
Monitoring: The Case Manager must determine, on an ongoing basis, if the
services and supports have been delivered, and if they are adequate to meet the
needs/wants of the consumer. Frequency and scope (face-to-face and
telephone) of case management monitoring activities must reflect the intensity
of the consumer‘s health and welfare needs identified in the individual plan
of services.
All eligible consumers shall be informed of case management services.
44
All eligible consumers shall be offered a choice of Case Managers when
available.
Case Managers shall clearly document the consumer‘s eligibility for case
management services in their evaluation and assessment.
Case Managers shall document in the Individual Plan of Service (IPOS) the
case management services that the consumer and support system are to
receive. The IPOS shall be in the form of goals, objectives, and interventions.
Case Managers shall document in the IPOS the exploration and use of natural
supports and community resources in assisting the consumer and his or her
support system to achieve their desired goals.
Case Managers shall document in the IPOS the amount, scope, frequency and
duration type of case management services that will be provided, including the
frequency of direct face to face monitoring contracts, which shall occur as
necessary and no less than monthly.
Case Managers shall document in the IPOS the interval at which the IPOS
shall be reviewed. They shall also document the amount, scope frequency
and duration of the services to be received in terms the consumer can
understand.
Case Managers shall review the IPOS at the interval identified on the IPOS. This
review shall include progress toward goals and objectives, appropriateness of
treatment goals/objectives, consumer and his or her support system‘s
satisfaction with case management services, and the consumer and support
system‘s ongoing appropriateness for case management services. This
review shall be documented in the case record.
Case Managers shall document in the IPOS services that are not available and
the alternative services that will be provided.
Case Managers shall deliver case management services as identified in the
IPOS. This delivery of services shall be clearly documented in the case record.
Individual Plan of Service. The Contracted Provider shall participate in the preparation
of an IPOS for each Gateway designated Consumer and to implement all applicable
goals and objectives. The IPOS shall detail the specific plan for Covered Services the
Consumer will receive from the Contracted Provider while in the Contracted Provider's
care, custody and supervision.
The Contracted Provider shall furnish all Covered Services identified as being the
responsibility of the Contracted Provider in each individual Consumer's IPOS. The
IPOS shall detail the nature of the service needs, as well as time frames and
measurable outcomes associated with goals and expectations in the IPOS. The IPOS
shall also detail the Contracted Provider‘s role in meeting the identified goals. The plan
for the Consumer‘s movement back into the Consumer's family setting, or semiindependent, independent, or other living arrangement in the least restrictive setting
shall be included in the IPOS and carried forward wherever possible and appropriate.
45
Each Consumer‘s IPOS is incorporated into this Agreement by reference, included in
the scope of Contracted Provider‘s Covered Services under this Agreement, and shall
represent part of the Contracted Provider‘s contractual obligations herein.
Each IPOS, and any amendment to the IPOS, must be pre-approved in writing by
Gateway or its designee in order for Covered Services to be eligible for payment to
Contracted Provider hereunder.
The Contracted Provider shall obtain and maintain a copy of the current IPOS for each
Consumer at the Contracted Provider‘s Residential Facility in addition to the home
records. Any Consumer‘s IPOS shall be made available to Gateway upon request.
Contracted Provider shall maintain these records for a period of at least six (6) years.
Case Managers shall monitor on an ongoing basis the welfare and safety of the
consumer. This shall be documented in the case record. Minimally this will
include one face-to-face contact per month in their living environment.
Case Managers shall be supported by the Contracted Provider or
Subcontractor, and not limited, in the information they provide about the
availability of, and access to, the full array of services and supports available
to the consumer and his or her support system.
Case Managers shall demonstrate coordination with the consumer‘s primary
care physician regarding health issues/problems/concerns.
For consumers age 21 or under, Case Managers shall demonstrate informing
the consumer with Medicaid insurance and his or her support system of the
availability of EPSDT services, and shall link the consumer and his or her
support system to these services, when appropriate.
For consumers age 21 or under, Case Managers shall demonstrate
coordination with the consumer‘s primary care physician regarding EPSDT
services.
The Contracted Provider or Subcontractor must maintain an up-to-date
resource
manual that can be conveniently accessed and used by the Case Managers.
The resource manual shall be updated on a yearly basis and shall include a
listing of informal and formal community resources. The listing for the
resource shall include the types of services provided, eligibility criteria, and
names and locations of the referral source.
Case Managers shall receive a minimum of 24 hours of training per year in
the area of case management and/or supports coordination specific to
the population they work with. Training will encompass sessions on the
Gateway Case Manager Technical Assistance Manual. The Contracted
Provider or Subcontractor shall maintain a record of these training hours.
The Contracted Provider or subcontractor shall maintain consumers‘ records
consistent with Gateway and Detroit-Wayne County Community Mental Health
Agency‘s policies and procedures.
46
Consumer‘s records shall be reviewed on an ongoing basis as part of the
Contracted Provider or Subcontractor‘s quality assurance/quality improvement
program.
The Case Manager will identify for consumers the after-hours clinical contact
information.
The Case Manager assists and coordinates the discharge plan with the hospital
discharge planner and the outpatient treatment team.
If a residential placement is needed or requested, the hospital treatment
team representative or provider Case Manager will contact Gateway
residential placement staff and fax a placement packet.
The Case Manager for children‘s services obtains a placement packet on
children to be placed in a child caring institution. The packet is forwarded to
the children‘s placement manager for review. Final decisions for placement
of children in child caring institution are made in Gateway‘s Children Unit.
The Case Manager will communicate information regarding consumers to
Gateway Community Health Clinical Care Managers and assist in
coordinating/developing crisis plans.
Requirements for Community Living Support Staff and Respite Workers
Individuals who provide CLS must:
Be at least 18 years of age.
Be able to practice prevention techniques to reduce transmission of any
communicable diseases from themselves to others in the environment where
they are providing support.
Have a documented understanding and skills in implementing the individual
plan of services and report on activities performed.
Be in good standing with the law (i.e. not a fugitive from justice, a convicted
felon, or an illegal alien).
Be able to perform basic first aid and emergency procedures.
Have successfully completed the Medication I, Medication II, Working with
People I and Working with People II modules of the Direct Care Staff training
Be trained in Recipient Rights annually.
Be an employee or contractor of a Gateway contracted provider of
Community Living Supports in an Unlicensed Setting (H0043).
Additional requirements:
a. Background checks:
 Must have a valid driver‘s license for at least 3 years and currently
be insured
 Drivers must have appropriate class license for driving vans, school
buses or larger trucks, as applicable (consumers cannot be used as
drivers)
47

b.
c.
d.
e.
f.
g.
No major violations in the last 3 years
o DWI, DUI, OUI, OWI, refusing to take a substance test, driving with
an open container of alcohol, negligent homicide or manslaughter
using a motor vehicle, operating a vehicle while in the commission of
a felony, aggravated assault with a motor vehicle, permitting an
unlicensed person to drive, reckless driving, fleeing or evading
the police/roadblock, resisting arrest, speed contest, hit and run
(bodily injury or property damage), failure to report an accident,
illegal passing of a school bus, or leaving the scene
o Staff that transport members cannot have any drunken driving
offenses on their record, even if it was a misdemeanor charge.
 No more than 8 points, broken down as follows:
o Maximum of 1 moving violation in the last 3 years in combination
with one at fault accident, or
o Maximum of 2 moving violations in the last 3 years with no atfault accidents or
o Maximum of 2 at-fault accidents in the last 3 years with no
moving violations
 Contracted providers must check driving record and criminal record
before they can start work and every year thereafter.
o See Attachment F for additional background check information
CPR/First Aid:
Certification must be obtained within 30 days of starting work.
Certification will last to the expiration date identified by the trainer. The
expiration dates need to be tracked by the staffing agency as part of
their routine personnel procedures.
Recipient Rights (RR) Training:
The standard is within 30 days for new hires and annually thereafter
TB test and blood borne pathogens (BBP) training:
The standard is within 30 days of hire and annually thereafter.
Other Requirements:
Photo ID
Social Security Card
I-9 form (citizenship)
At this time, finger printing is not required for Community Living Support Staff,
Family Friend Respite workers, Respite workers, and/or Hospital Sitters.
All of the above standards apply for Respite workers with the exception of
Family Friend Respite workers. For staff working only as Family Friend respite
workers the standards are as follow:
Photo ID
Social Security Card
No background check is required for this class of worker
48
Verification Guidelines for Community Living Support Staff and Respite Workers
Contracted providers of Community Living Support Staff and/or Respite shall take the
following steps to ensure the Medicaid covered services and supports paid for and
reported to Gateway were delivered appropriately:
1. White out is not to be used on timesheets. All timesheets shall be original
documents and any errors need to have a single line drawn through them and
need to be initialed by the person correcting the error. Timesheets are not to
be pre- signed and copied.
2. Timesheets are not to be reused.
3. Timesheet must be dated and signed by the paid support staff. The consumer
name and an authorized signature (typically the individual consumer or their family
member will counter-sign the timesheets) must be on each timesheet.
4. A progress note is to be filled out that indicate what was done for/with the
consumer during the time worked. This documentation should relate back to the
specific reasons/ goals for the staffing identified in the Person-Centered Plan.
5. Consumer families need to fill out an “authorized signature” (for whoever will be
countersigning the timesheets). This signature can then be used to verify
signatures on timesheets.
6. Any unusual incidents, including but not limited to questionable reporting of time
by paid support staff, shall be documented on an Incident Report form and
submitted to both the Agency and Gateway per established guidelines.
7. Each paid support staff and persons completing the authorized signature form
shall receive information about the False Claims Act, Whistleblowers‘
protections, and any contractor specific policies for detecting and preventing fraud,
waste and abuse. Documentation that this information was shared must be
kept as part of the personnel file for each paid support staff.
49
Section VI
Utilization Management
Introduction
It is the policy of Gateway to authorize payment in an orderly and efficient manner for all
medically necessary covered services requiring such authorization and identified during
the Person-Centered Planning process. The authorization process is not intended to
interfere with the timeliness of service delivery and the terms and conditions contained
herein shall be interpreted strictly in accordance with the terms of individual provider
contracts, and as applicable, the terms of the Michigan Department of Community Health
Medicaid Provider Manual.
Definitions (These definitions are applicable and take precedence over all others within
this section of the Provider Manual):
Administrative Non-Certification – An administrative communication, issued by a
Gateway Director, that a particular service or LOC has not been requested for
Certification or Authorization by Gateway in accordance with Gateway
authorization request timeframes.
Appeal - A request by a member, member-designated representative, or provider
acting on a member‘s behalf, to review a medical necessity determination made in
response to a request for services.
Authorization - Approval for a specific covered service to be delivered as a covered
benefit to a covered member. Payment is subject to member eligibility, provider
licensure/certification and benefit limits at the time services are provided. A decision
rendered by a qualified professional who has been delegated the authority by Gateway, to
approve a request for covered clinical services as meeting the clinical care criteria of
Medical Necessity. (DWCCMHA/MCPN Contract). When applicable to Medicaid services,
Gateway authorization and approval decisions will be made according to level of care
guidelines established and published by MDCH in its Medicaid Provider Manual.
Authorized Services – Covered services determined by or on behalf of Gateway to be
medically necessary and eligible for payment/reimbursement in accordance with the
terms of the contract between the provider and the Network, and applicable
Medicaid regulations. While all funded services require authorization by Gateway, only
specific subsets require prior authorization.
Authorized/Certified (or authorization/certification): Means that Gateway, or the
representative whom it has designated to perform prior authorization/utilization
management on its behalf, has screened the candidate and has approved the inpatient or
partial hospitalization, the specialized residential or crisis residential level of care
services or ACT, Skill Building or Home-based services to be medically necessary for
the individual and has indicated so by providing evidence to the admitting facility.
50
Certification – Confirmation that a particular level of care of a covered benefit has been
determined by Gateway, or someone acting on its behalf, to meet the medical necessity
criteria prerequisite to authorization of payment. Any inpatient psychiatric admission not
certified by or on behalf of DWCCMHA is not a benefit of the Medicaid program.
(DWCCMHA/MCPN Contract)
Clinical Care Coordinator - A Qualified Professional (Master‘s level clinician,
Psychologist, Social Worker or Licensed Professional Counselor, with three years postgraduate experience with appropriate State Licensure licensed registered nurse who has
been delegated the authority by Gateway, to review a request for covered clinical
services as meeting the criteria of Medical Necessity.
Clinical Non-Authorization - Confirmation by a physician that has been authorized by
Gateway to do so that a requested service does not meet medical necessity criteria and is
therefore subject to denial or other adverse decision.
Concurrent Review - The process of determining the medical necessity of extending the
delivery of a specific level of care, such as, for, e.g., inpatient hospital, state hospital,
partial hospital, crisis residential, or specialized residential/child caring institutional
services, ACT, Skill Building or Home-based services when such continued level of care
has been requested and the previous authorization has expired.
Denial of Authorization - An adverse authorization decision made by or on behalf of
Gateway by an authorized health care professional with appropriate expertise, in the
case of inpatient hospital, state hospital, partial hospital, crisis residential services,
ACT, Home-based or Skill Building. Services.
Inpatient Hospital and Partial Hospitalization Services First Level Appeal - The next
level of appeal that can be requested following a Reconsideration Review. This level of
appeal is performed by physicians authorized to do so on behalf of Gateway.
Initial Inpatient Hospital and Partial Hospitalization Services Authorizations - The
pre-authorization that permits the admission of the eligible individual into the level of care
requested.
Inpatient Hospital and Partial Hospitalization Services Reconsideration Review
– The first level of appellate review of a denial of authorization for services. A Request
for Reconsideration Review must be filed within thirty days of the Clinical NonCertification at issue. The clinical reconsideration is sent to a different physician for
review and decision.
Inpatient Hospital and Partial Hospitalization Services Second Level Appeal The next level of appeal that can be requested following a First Level Appeal. This level
of appeal is performed by Detroit-Wayne County Community Mental Health Agency.
51
Gateway will send the case along with all supporting documentation to the Detroit-Wayne
County Community Mental Health Agency for a final determination if the provider has
requested the final level of appeal.
Length of Stay (LOS) - The number of days that a member remains in a given level of
care. (Operations)
Level of Care (LOC) - The intensity of professional care required to achieve the treatment
objectives for a specific episode of care. (Operations)
Level of Care (LOC) Protocols - Severity of Illness/Intensity of Service Protocols
provided by the Michigan Department of Community Health (MDCH) and DWCCMHA,
each as amended from time to time, as part of a utilization management system, which are
intended to monitor the appropriateness of mental health care. Severity of Illness refers
to the nature and severity of the signs, symptoms, functional impairments, and risk
potential related to the person's complaint. Intensity of Service pertains to the setting of
care, to the types and frequency of needed services and supports, and to the degree of
restriction necessary to safely and effectively treat the individual. (DWCCMHA/MCPN
Contract)
Pre-Authorization/Prior Authorization – Any authorization that is required and/or
rendered prior to the delivery of particular services or levels of care.
Physician – Any physician participating in the utilization review process as an authorized
representative of Gateway.
PREST – An independent review organization under contract with Gateway comprised of
board certified psychiatrists with many specialty areas (i.e., children, elderly, etc.)
Provider – as used in the portion of this policy entitled ―Inpatient Hospitalization and
Partial Hospitalization Clinical Appeals,‖ means a provider of inpatient hospitalization or
partial hospitalization services.
Authorization Process
Gateway is responsible for both the initial and, if applicable, (based on the service)
ongoing concurrent authorizations for those members who meet eligibility criteria. These
services require an authorization prior to services being delivered. Gateway is
committed to using the highest standards of clinical expertise and managed care. The
goal is to provide quality of care and outcomes for members of behavioral health
services in the Gateway Community Health. Gateway clinical staff:
Develop appropriate utilization management (UM) guidelines and protocols.
Review prior authorization requests within established time frames per authorization
guidelines.
52
Refine, edit, update and disseminate utilization management criteria to
providers and other staff.
Integrate utilization of diagnostic formulation, the clinical assessment, the
treatment/service plan, and the results of assessments related to requests for prior
authorization for appropriate and medically necessary services.
The initial authorization/continued stay review process helps to ensure that appropriate
services are delivered and that either anticipated progress is being made toward the
established clinical goals or the treatment plan is adjusted accordingly. This step allows
Gateway to obtain necessary information to document the medical necessity of ongoing
care.
To request authorization for inpatient services, providers must contact Gateway at 1-800973-4283 or 313-262-5050 24hours a day, 7 days a week. For outpatient services,
providers will use the numbers above during normal business hours Monday thru Friday
from 8:00 a.m. to 5:00 p.m. If the outpatient provider prefers, information with the
request for authorization may be faxed to Gateway at 313-875-4715.
For each eligible member for whom the provider has submitted an initial authorization
request, there is an initial amount of each service that is authorized for the particular
level of care, if the UM criteria is met.
To obtain authorization or for re-authorization for additional services the provider
should provide clinical criteria prior to the last anticipated authorized service date. This
review will include, but is not limited to, the following information:
Presenting problem
Diagnosis
Current symptoms
Current level of functioning
Prior psychosocial, psychiatric, and substance abuse history and prior treatment
Mental status
Medications (dosage and side effects)
Medical complications and significant medical history
Treatment plan and progress toward goals
For outpatient authorizations the provider should provide the above
information along with an IPOS.
Decisions for inpatient decisions are rendered within 3 hours of the time requested.
Outpatient authorization decisions are rendered within 3 business days of request.
Utilization Guidelines and Management
Gateway works proactively with providers to build consensus around the appropriate
level of care and treatment plan. Gateway believes that the relationship between
treatment standards and clinical judgment is one of assistance and collaboration rather
than one of control.
53
To effectively authorize and review care, objective and measurable utilization
management criteria based on sound clinical principals and processes have been
developed and included in the Michigan Department of Community Health Medicaid
Provider Manual. The elements of these service listings are the basis for the
Gateway utilization management process. These criteria support fair, impartial and
consistent utilization management decision making that services the best interest of our
members.
Gateway seeks to ensure that each member can access needed services with the
appropriate provider, at the correct intensity of service and duration of care with special
attention to involvement of, and collaboration with natural and community supports.
Inpatient Hospitalization and Partial Hospitalization Clinical Appeals
A clinical appeal is a request for a reconsideration of a determination that the requested
inpatient hospitalization or partial hospitalization service does not meet medical necessity
criteria. There are several levels of appeal available. The inpatient hospitalization and/or
partial hospitalization Provider has up to 30 calendar days from the date of issuance of
Gateway‘s written Clinical Non-Certification Notice to submit a written request for
appeal.
Requests received beyond the 30 day time frame will not be eligible for review. A failure
to file a timely request for reconsideration and/or appeal of any Clinical Non-Certification
determination that has been issued or upheld constitutes constructive agreement with
such earlier Clinical Non-Certification and a withdrawal of the previous request for such
services or level of care.
1.
Reconsideration
a. Standard Reconsideration
When an adverse determination is made for continued stay in any inpatient
hospitalization or partial hospitalization level of care requiring Pre-Authorization
and the member is no longer in treatment at that level of care, a standard
reconsideration review may be requested by the member, member
representative or Provider. The Clinical Care Manager may request the medical
record from the provider and forwards the request with relevant documentation
to a physician.
The member, member representative or Provider must request the
reconsideration within 30 calendar days of the date of the written notification of
the adverse determination.
A Physician reviews pertinent information and makes a determination within 30
calendar days of receipt of the medical record. Notification of the determination
will be sent to the member and facility in writing.
54
For cases where a non-authorization determination is upheld, the written
notification includes the name of the Physician who rendered the determination,
the clinical rationale, and a description of the First Level Appeal process.
b. Expedited Reconsideration
When an adverse determination is made for continued stay in any prior
authorized level of care and the member is currently in treatment, the Care Manager
upon request for reconsideration will forward the request for an expedited
reconsideration, with relevant documentation, to a Physician.
The member, member representative or Provider must request the expedited
reconsideration within 2 days of the non-authorization decision.
A Physician will attempt to contact the treating physician telephonically, to conduct
the review within 2 business days of receipt of the request for expedited
reconsideration.
The Physician informs the treating physician of his/her determination at the time
of the review and explains the first level of the clinical appeal process.
Notification of the review determination is generally sent to the member and the
treating physician (and/or facility) in writing within two business days of the
review. For cases where a non-certification an/or non-authorization determination
is upheld, the written notification includes the name of the Physician who
rendered the determination, the clinical rationale, and a description of the First Level
Appeal process.
2.
First Level of Appeal
a. Standard First Level Appeal
A Standard First Level Appeal is offered when the standard reconsideration is
upheld. The Care Manager may request the medical record from the Provider and
forwards the request with relevant documentation to a Physician.
The member, member representative or Provider must request the Standard First
Level Appeal within 30 calendar days of the date of the written notification of the
results of the reconsideration.
A Physician reviews pertinent information and makes a determination within 30
calendar days of receipt of the medical record.
Notification of the determination will be sent to the member and treating provider in
writing.
55
For cases where a non-authorization determination is upheld, the written
notification includes the name of the Physician who rendered the determination, the
clinical rationale and a description of the Second Level Appeal Process.
b. Expedited First Level Clinical Appeal
An expedited First Level Appeal is offered when the expedited reconsideration is
upheld. The Clinical Care Manager requests a copy of the medical record and
forwards the request with relevant documentation to a Physician.
The member, member representative or Provider must request the First Level
Appeal within two (2) business days of receipt of the written notification of the
results of the expedited reconsideration.
Expedited First Level Appeal for admissions to any prior authorized level of care
will be completed within two (2) business days of receipt of the requested clinical
information.
The Physician informs the attending or treating clinician (or designee) of his/her
determination at the time of the review and explains the Second Level Appeal
process.
Notification of the review determination is sent to the member and the treating
clinician (and/or facility, if applicable) in writing within two (2) business day of the
review. For cases where a non-authorization determination is upheld, the written
notification includes the name of the Physician who rendered the determination, the
clinical rationale, and a description of the Second Level Appeal process.
3.
Second Level Appeal
If the member, member representative or Provider wishes to appeal the results
of the First Level Appeal, a Second Level Appeal is conducted by the DetroitWayne County Community Mental Health Agency (DWCCMHA).
In expedited cases, the member, member representative or Provider must
request the Second Level Appeal within two (2) business days of receipt of the
written notification of the results of the first level appeal. The DWCCMHA will
make a determination in accordance with the clinical urgency of the request and
the member‘s clinical condition.
In standard cases, the member, member representative or provider must request
the Second Level Appeal within 30 calendar days of the date of the written
notification of the results of the first level appeal. The DWCCMHA will make a
determination within 30 calendar days of receipt of the clinical information.
The DWCCMHA will forward the results of the Second Level Appeal to Gateway
who will notify the member and the treating clinician (and/or facility, if applicable)
56
of the review determination within two (2) business days of the determination.
4.
A d m i n i st r a t i ve F a ir H e a r in g
Medicaid recipients receiving Medicaid-covered services have the right to request
an Administrative Fair Hearing at any time after the initial non-authorization
determination is made.
5.
Alternative Dispute Resolution Process
Non-Medicaid recipients or Medicaid recipients receiving services not covered by
Medicaid may access the Alternative Dispute Resolution Process after
exhausting the Gateway and Agency appeal processes.
The Alternative Dispute Resolution Process must be requested within ten (10)
business days of notification of the results of the Gateway and Agency appeal
processes.
Discharge Day in a 24 Hour Setting
This policy applies to all contracted facilities that provide 24-hour service (hospital,
residential facilities, crisis residential facilities, child caring institutions, etc.)
Provider is to follow guidelines as designated in the authorization policies specific to
Gateway. Provider will be issued an authorization number for all authorized days/units,
provided the consumer meets medical necessity criteria.
Once the day of discharge has been determined, authorization will not include payment
for the day of discharge in a facility that provides 24-hours of service. These include
settings where the individual has been admitted for bed occupancy with the expectation
that the individual will remain at least overnight, even when it later develops that the
individual can be discharged or is transferred to another facility by 11:59 p.m. and does
not use the bed overnight.
Days of care provided to a consumer are in units of full days, beginning at midnight and
ending 24 hours later. Medicaid covers the day of admission but not the day of
discharge. If the day of admission and the day of discharge are the same, the day is
considered an admission day and counts as one day. Unless there are extenuating
circumstances, the discharge day will not be authorized.
Residential Reconsideration Review
Residential providers that do not agree with the level of care for their residents as
determined by Gateway or the primary provider agency are invited to express their clinical
concerns with Gateway through the Appeals department by completing a
reconsideration request form. This form is available on the provider portal. It can also
be requested through the appeals department.
57
This policy is intended solely to assist Gateway and its primary provider agencies in
serving their consumers and expressly does not confer on the residential provider any
legal standing or contractual rights of its own to appeal or otherwise contest any level
of care determinations made by or on behalf of Gateway or its primary provider
agencies.
58
Section VII
Quality Improvement
Introduction
The mission of the Quality Improvement (QI) Department is to institute processes that
assure systematic approaches are used to 1) determine the relevant standards and
best practices, 2) the processes and activities to assess performance, 3) the
measurement of performance against defined standards and/or best practices, and 4)
the improvement strategies to improve performance and consumer outcomes.
Further, to outline the systematic approach to achieve and measure performance
improvement in all operations, both clinical and non-clinical, that impact consumers‘
access, health and safety, quality of life and satisfaction, person-centered planning,
service-related processes and outcomes.
QI also seeks to create, sustain and enhance a network of culturally aware providers who
are committed to delivering quality supports following these same principles in a timely
manner.
Contact Information
L. C. Smith, LMSW, Quality Manager – (313) 263-2452
Incident Reporting
Any of the following circumstances and/or situations occurring in a Gateway
Residential or Outpatient setting must be reported to Quality Improvement within 24
hours of occurrence. They are:
1.
2.
3.
4.
5.
6.
Death of a recipient
Physical illness requiring admission to a hospital
Accidents requiring emergency room visits and/or admissions to hospitals
Serious challenging behaviors not previously addressed in the IPOS
Arrest or conviction of recipients
Medication errors which could lead to adverse health outcomes
All Incident Reports are to be completed and faxed, within 24 hours, to the DWCCMHA
ORR at (313) 833-2043, the QI department at (313) 263-2453 or (313) 263-2513, and
the responsible CMHC.
Death Reporting
Definition: The Death Reporting procedure is defined as a procedure to notify Gateway
of a consumer‘s death and to process the death of Gateway consumers.
59
STANDARDS:
1.
Contracted Providers are to report the death of a Gateway consumer within
one (1) business day by calling the 24 Hour number: 1-800-973-4283. During
the call the representative will complete the Preliminary Death Report form
(see Section XI) using information provided during the call.
2.
A Mental Health Professional (excluding Adult Foster Care Home
Providers) will complete the Report of Recipient Death (see Section XI) and
include all relative documentation/information within ten (10) business days of
the consumer‘s death. The Report of Recipient Death should be faxed to GCH
Quality Department (313-263-2453).
3.
All deaths are Sentinel Events and, as such, require a Sentinel Event Report
(see Section XI) to be completed by a Mental Health Professional (excluding
the Adult Foster Care Home Provider), within three (3) business days prior to
the Report of Recipient Death, or afterwards, depending on the information
gathered during the completion of the Report of Recipient Death. The
Sentinel Event Report should be faxed to the GCH Quality Manager, at 313263-2453.
Sentinel Events
It is the policy of the Gateway that occurrences of potential Sentinel Events, and
substantiated Sentinel Events, involving Gateway consumers be reported, reviewed,
investigated and subjected to a root cause analysis when appropriate. Follow-up
action(s) are to be taken in a timely manner and compliant with regulatory and
contractual guidelines.
Sentinel Events: An unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof. Serious injury specifically includes loss
of limb or function. The phrase ―or risk thereof‖ includes any process variation
for which a recurrence would carry a significant chance of a serious adverse
outcome. Criteria to determine a Sentinel Event are:
Death of recipient that does not occur as a natural outcome to a chronic
condition (e.g., terminal illness) or old age;
Serious illness requiring admission to a hospital (This does not include
planned surgeries, whether inpatient or outpatient or admissions directly
related to the natural course of the person‘s chronic illness, or underlying
condition);
Serious injury (including but not limited to an accident or
suspected abuse) requiring emergency room or emergency care center
visit and/or admission to a hospital. (This includes injuries of sufficient
severity to require visits to a hospital and/or medical center urgent care
clinics emergency rooms, and/or admissions to hospitals);
60
Serious challenging behaviors not already addressed in a treatment
plan and that include significant (in excess of $100) property damage,
attempts at self-inflicted harm or harm to others, or unauthorized leaves of
absence, for, e.g., a person‘s escape from a locked protective treatment
setting; person to person altercation requiring medical attention, person
to person sexual assault or occurrence of sexual intercourse while in a
locked protective treatment setting;
An arrest or conviction of a felony or violent offense. (Police
transport to a screening center on a petition is not an arrest).
Medication error consisting of (a) wrong medication; (b) wrong dosage;
(c) missed dosage; or (d) improperly administered dosage resulting in death
or serious injury or the risk thereof. (It does not include instances in which
consumers have refused medication.)
Credible allegation of sexual abuse, neglect, or exploitation.
The purpose of this policy is two-fold:
1. To achieve compliance with DWCCMHA's (the Agency's) "Sentinel Events" policy
and peer review process in accordance with the Michigan Mental Health Code,
Section 330.2200 and all applicable Federal, State, and Local standards; and
2. To accomplish the goals listed below.
The goals of this policy are:
1. To have a positive impact in improving consumer care and preventing Sentinel
Events;
2. To focus the attention of this organization on an incident or Sentinel Event to
understand the causes that underlie the event, and to make changes in policy or
procedures when needed.
3. To increase the general knowledge about incidents, critical incidents or Sentinel
Events, their causes, and strategies for prevention.
Residential Monitoring
Gateway mandates that residential settings where members receive Covered Services
are sufficient to ensure the health and safety of those members. Therefore, Gateway
routinely monitors residential providers to assess compliance with health and safety
standards, and, with any local, state, or federal standards that Gateway, in its sole
discretion, deems applicable.
Monitoring of Residential Provider Sites
An Abbreviated Health and Safety Assessment is performed for all routine monitoring of
contracted specialized residential settings where there are Gateway residents and is
generally completed on a quarterly basis.
61
A Comprehensive Health and Safety Assessment is performed at least annually. Such
assessments may, at the sole discretion of Gateway, be required for other residential
settings.
Gateway reserves the right to monitor more frequently as, in their sole discretion, they
deem appropriate.
Health and safety concerns and possible Recipient Rights violations are identified by the
Quality Improvement Department and all other appropriate agencies.
The assessment will include a face-to-face interview with a member and will include
an evaluation of the level to which their health and safety needs are being identified and
met.
The assessment may include a review of the provider‘s written policy and records for the
safeguard and control of Consumer funds.
A copy of the assessment will be given to the home provider by the Designated Monitoring
Agency. All completed monitoring assessments done within the month are due to
Gateway by the 15th of the following month by the monitoring agency.
A progress note reflecting the review agent‘s conversation with the consumer in the
home, that the consumer‘s chart was reviewed, the date, time, and appropriate service
code will be placed in the consumer‘s chart.
The Quality Improvement Department or designee reviews all information to confirm the
residential setting is or is not in substantial compliance with all rules and guidelines
established by Gateway.
If the residential site substantially meets health and safety criteria, routine monitoring will
continue. If the residential setting does not meet these criteria, remedial action will be
required, and a corrective action plan or, if circumstances require, a Plan of Correction is
put in place. The cost of any such monitoring is allocated to the impacted provider.
The Plan of Correction and implementation is monitored by the Quality Improvement
Department or designee. The monitoring can be as frequent as necessary as identified by
the Quality Improvement Department.
It is the responsibility of the Gateway Quality Improvement Department to ensure all Plans
of Correction are kept updated. Providers who are not compliant in implementing the
required plans of correction will be subject to review utilizing the Scope and Severity
Protocol for remediation due to their non-compliance with contract requirements. Gateway
reserves the right to visit any contracted or approved residential setting at any time.
All information is kept on file for a minimum of six years.
62
Associated Forms
Comprehensive Health and Safety Assessment
Abbreviated Health and Safety Assessment
Unlicensed Health and Safety Assessment
Provider Application
Provider Contract
Plan of Correction
Emergency Preparedness
Emergency Preparedness for residential providers and supports coordinators of persons in
community settings is very important. All residential providers are required to have an
emergency preparedness kit consisting of:
4 oz bottle of water for each consumer
Diapers for incontinent consumers
Batteries
Battery operated radio
Flashlights
Hand sanitizer/wet wipes
Rain ponchos
Emergency medical charts
List of emergency numbers
First-aid kits – travel size
Blood-borne pathogen kit
Socks/gloves
Snacks (such as cheese or peanut butter crackers)
Blankets
This kit is for use if there is an emergency that requires the staff and consumers to leave
the home (i.e. Fire) and designed to meet the immediate needs of consumers until they are
relocated.
Providers are also required to maintain a three-day emergency food supply. This food
supply is separate from the rest of the food supply and must be rotated on a regular
basis to avoid the food from becoming out dated. Below is a sample of what the provider is
required to have to feed consumers for three days due to an emergency such as a power
outage.
Emergency Food Supply (enough for 3 days without power)
Manual can opener (somewhere in the residence)
Powdered milk, which should be labeled grade A and pasteurized, may be
used as a beverage in cooking and baking (emergency use only)
Canned food
Canned fruits
Bottled water
Items such as Vienna sausage, tuna fish, granola bars
Peanut butter
Crackers
63
Emergency Sample Menu
Breakfast
Cold cereal with milk
Fruit cup
Lunch
Tuna/peanut butter sandwiches
Chips, Juice or Kool Aid
Dinner
Canned beans
SPAM or canned chicken
Canned Fruit
Ice tea
Snack
Peanut butter crackers
Granola bars
Providers must also maintain compliance with AFC Licensing rules in regards to
consumer safety which consist of complying with:
Fire Drills
Evacuation Assistance Scores (E-scores)
Evacuation Difficulty Index Score
Protection Plans
For specifics of this requirement, please see: www.michigan.gov/cis
Go to: Family and Health Services, Adult foster Care, Appendix FA procedure for determining Evacuation Capability
Forms for this rating can be found in the NFPA 1985 Life Safety Code handbook or can be
purchased at www.nfpacatalog.org
As part of the residential monitoring process, providers are monitored on a quarterly
basis for compliance with emergency preparedness. If you have additional questions
regarding this procedure, contact the Quality Improvement Department or your
Provider Service representative.
Vehicle Safety
It is the policy of Gateway that all contracted providers and subcontractors and their
employees who transport consumers will comply with the State of Michigan laws
governing seat belt and child restraint seats. Unless an employee or a consumer has
a written medical exemption from a licensed physician in their personnel file/case
record, seat belts are to be worn by all drivers and passengers.
(With the exception of those exemptions listed in Sections 257.710d and 257.710e of
the Michigan Vehicle Code, Act 300 of 1949).
In order to ensure compliance with State laws, Gateway requires contractors,
subcontractors and their employees who transport members adhere to the following
standards:
Michigan Vehicle Code (Excerpt), Act 300 of 1949.
In addition to the Michigan Vehicle Code, all staff and passengers in a
64
vehicle will wear seatbelts whenever the vehicle is in motion unless they have
a written medical exemption from a licensed physician or as exempted in
Sections 257.710d and 257.7103 of the Michigan Vehicle Code, Act 300 of
1949.
Staff who transport consumers whether in their own personal vehicle or a
contracted providers vehicle shall possess a valid, unrestricted driver‘s
license and or chauffeur‘s license when necessary with current motor vehicle
insurance, as well as, valid motor vehicle registration.
Contracted providers and subcontractors shall have policy and procedures
regarding transportation of consumers and vehicle safety.
In the event that a consumer is wheelchair bound and is being transported
in their wheelchair staff must ensure that the wheelchair is properly secured in
the vehicle.
In the event that a consumer displays a pattern of failing to utilize their
seatbelt during transportation the Interdisciplinary Team will address this
safety issue in the Individual‘s Plan of Service and Behavior Management
Committee as appropriate.
65
Section VIII
Compliance
Gateway is committed to consumers, employees, contractual providers and the
community to ensure business is conducted with integrity, in compliance with the
requirements of applicable laws and sound business practices, and with the highest
achievable standards of excellence.
The Gateway Compliance Plan draws on recommendations from the following four major
sources:
1.
Federal regulators that include the Office of the Inspector General
(OIG) of Health and Human Services (HHS) Guidelines.
2.
National Legal Compliance experts
3.
National Behavioral Health experts
4.
National MBHO Accreditation experts
The compliance plan provides a framework for Gateway to comply with applicable fraud
and abuse statutes, regulations and program requirements. The key intentions of the
Compliance Plan are to:
Minimize organizational risk and improve compliance with the billing requirements
of Medicare, Medicaid and all other applicable federal health care programs.
Maintain adequate internal controls (paying special attention to the Agency‘s
identified high risk areas.
Reduce the possibility of misconduct and violations through early detection.
Reduce exposure to civil and criminal standards.
Encourage the highest level of ethical and legal behavior from all
employees.
Educate employees, contract members, Board Members, and stakeholders of
their responsibilities and obligations to comply with applicable local, state and
federal laws and regulations including licensure requirements, as well as,
accreditation standards.
Promote a clear commitment to compliance by taking action to uphold such laws,
regulations and standards.
Provider Monitoring and Site Visits
Provider Monitoring and/or Audit visits will be conducted to determine compliance with
licensing, contractual and regulatory facility standards.
Providers must meet all standards that apply for all audits conducted. In some cases,
compliance may be determined by a percentage of compliance, i.e. 95% or higher. In
other cases, there must be 100% compliance.
66
New providers will receive reviews before a contract is finalized. Follow up reviews will
be scheduled within six months of contract start date.
All Providers will receive, at a minimum, an annual audit.
Safety and environmental reviews will be conducted, as well as testing for compliance
with the Michigan Mental Health Code, and any other related regulatory, and contractual
obligations that may include review of staff personnel records training records and
clinical compliance. As required, policies and procedures of the organization will also be
reviewed.
Member charts will be reviewed to determine if appropriate care is being rendered,
recorded, and monitored as required. This will include the charts of the Clinical Provider
and the AFC Provider, as appropriate. Staff training records will be reviewed to ensure
all required training is being completed. AFC personnel audits will include areas such
as: Direct Care Worker Training, Recipient Rights, Person Centered Planning, CPR,
and First Aid.
The Provider will receive Follow up visits, targeted at review of areas of deficiency,
which will be conducted on a schedule dependent on the level of violation and type of
audit. Providers will receive results of the follow up audits will in writing.
Monitoring will also be repeated on a periodic basis to assure that identified corrections
have been implemented and are effective, and/or to confirm and document ongoing
compliance when no specific problems have been identified.
Providers may also receive unannounced site visits by Gateway staff at any time. If a
provider has been determined to be sufficiently non-compliant with contract terms or
quality of care poses potentially high health, safety or other liability risks unannounced
site reviews will be conducted in order to satisfy the concerns or questions as to
compliance or performance.
Providers must also meet requirements Medicaid Claims and Billing.
Providers must be accurate in billing submissions to ensure appropriate billing
practices are being utilized that are consistent with CMS, MDCH guidelines and any
other contractual arrangements made with GCH.
Other Provider documentation requirements include: consumer eligibility for services,
whether or not the services provided were identified in the IPOS, if the billing units
match case record documentation, staff providing service have appropriate credentials,
and other items required by MDCH, D-WCCMHA and/or GCH.
Providers will receive results of all audits in writing.
Depending on the nature of the non-compliance/level of violation GCH may include the
requirement for a submission of a Plan of Correction (POC).
67
The POC will be reviewed by Quality and/or Compliance Department staff. Submission
and approval of a POC becomes a legal obligation of the provider under the provider
contract.
Patterns of deficiencies will be grounds for disciplinary action up to restriction or
termination of contracts for network providers and suspension or termination of
providers.
In preparation for the audit, Providers are Required To:
Have all requested charts present and available at the time of the audit.
Allow adequate access to the Electronic Medical Records to the charts being
audited to allow for the completion of the audit
Designate a representative who will be responsible for assisting with the audit
process as necessary, i.e. attempting to locate documents within the chart
provided, and providing copies of documents requested
The representative will, in the cases of identified deficiencies, provide written
confirmation by initialing the audit form, and/or comment regarding any
disagreement with findings.
Gateway will:
Furnish a list of the consumer charts to be audited (at least 1 day prior to the
audit date.)
Review records as they are presented during the audit. Additions to the record
that are located in a staff office or other places, cannot be added when the audit
has started.
Review audit outcomes and coordinate with Finance staff if claims are found to
be non-compliant (i.e. – no Treatment Plan, expired treatment plan, billed and
paid units do not match service units documented.
Antikickback Law
Because Gateway and its providers are receiving Medicaid funds, the Federal
legislation (Medicare and Medicaid Patient Protection Act of 1987, as amended 42
U.S.C. 1320a-7b.), also known as the ―Antikickback Law‖, is the law that applies.
The Act prohibits individuals from soliciting or accepting anything of value including
gifts, payments, services, favors or anything else that might appear to influence the
actions of the individual. An offer of a gift by a provider to Gateway staff may be
interpreted as an attempt to influence actions. That may not have been the intention,
but if this action appears to be an attempt to influence, it is prohibited.
Providers should never offer a gift of cash or financial instruments (e.g., checks, stocks)
to Gateway staff.
68
Section IX
Member/Customer Service
It is the function of the Customer Service Unit to be the entry to Gateway Community
Health (GCH) and to convey an atmosphere that is welcoming, helpful and informative
to all individuals that contact the organization with consumer-related questions and
issues.
All callers will be served with respect, provided clear and concise information within the
scope of the position of the Customer Service Representative who will also refer callers
to others in or outside the organization as appropriate.
In order to assure prompt access to consumer service, GCH has strict telephone
service standards. The average speed of answer for customer service lines is 30
seconds or less. The abandonment rate for the customer service line is 5% or less.
Members, providers or facilities wishing to initiate medical necessity determination
procedures can contact Gateway‘s toll-free Customer Service Unit 7 days per week,
365 days per year.
24-Hour Customer Service Lines
313 - 262 - 5050
800 - 973 - 4283
TDD: 313 - 875 - 4065
The GCH Customer Service Unit will also provide information regarding grievance and
appeals, Fair Hearings, local dispute resolution processes, Recipient Rights and claims
issues.
Customer Service Standards for Providers
It is the function of the customer services unit to be the entry to your facility and to
convey an atmosphere that is welcoming, helpful and informative.
Functions:
Welcome and orient persons to services and benefits available.
Provide information about how to access mental health and other community
services.
Provide information about how to access the various rights processes.
Help persons with problems regarding benefits.
Assist people with and oversee local complaint and grievance processes.
Standards:
There shall be a designated unit called ―Customer Services‖.
69
There shall be a minimum of one FTE dedicated to customer services. There
shall be sufficient staff to meet the needs of the people accessing the facility.
There shall be a designated toll-free customer services telephone line and
access to a TTY number. The numbers shall be displayed in the provider‘s
brochures and public information materials.
Telephone calls to the customer service unit shall be answered by a live voice
during business hours. Telephone menus/trees are not acceptable. If
messages are taken due to high volume, there must be a response to each
within one business day.
The hours of customer service unit operations and the process for accessing
information from customer services outside of normal business must be
publicized.
All providers will have a customer handbook which shall contain the staterequired topics.
Upon request, the customer service unit shall assist consumers with the
grievance and appeals, and local dispute resolution processes.
Customer Service Monthly Tracking Report is due by the 3rd of each month.
Grievance and Appeal logs are due to Gateway by the 10th of each month.
The Consumer Handbook that shall be used by Member Services on behalf of Gateway
and the Primary Providers that are part of their contracted provider network shall be
DWCCMHA‘s Consumer Handbook. The handbook is available by contacting
DWCCMHA‘s Customer Service Department at (313) 833-2500.
Upon request, Customer Service shall assist beneficiaries with the grievance, appeals,
local dispute resolution processes, and coordinates as appropriate with Fair Hearing
Officers and the DWCCMHA Office of Recipient Rights.
Cultural Competency
Gateway staff, contracted providers and subcontractors shall assure sensitivity,
demonstrate accommodations and cultural competencies to individuals of diverse ethnic
and cultural backgrounds in the provision of services.
Culture: is broadly defined as a common heritage or set of beliefs, norms, and values
shared by a group of people. There is great diversity within each broad category and
individuals may identify with a given racial or ethnic culture to varying degrees.
Others may identify with multiple cultures, including those associated with their religion,
profession, sexual orientation, region, or disability status.
Cultural Competency: is an approach to delivering mental health services grounded in the
assumption that services are more effective when they are provided within the most relevant
and meaningful cultural, gender-sensitive and age-appropriate context for the people being
served.
70
In 2006, the United States Surgeon General defined cultural competence in the most
general terms as ―the delivery of services responsive to the cultural concerns of racial and
ethnic minority groups, including their languages, histories, traditions, beliefs, and values‖.
Most of the time, the term cultural competence refers to sets of guiding principles,
developed to increase the ability of mental health providers, agencies or systems to meet
the diverse communities, including racial and ethnic minorities.
Cultural Diversity: Refers to differences in race, ethnicity, language, nationality or religion
among various groups within a community.
Ethnic: A large group of people classed according to common racial, national, tribal,
religious, linguistic, or cultural origin or background.
Standards
All contracted providers and their subcontractors shall have mechanisms in place to assure
that sensitivity and accommodations are made for individuals with diverse ethnic and
cultural backgrounds. Staff shall receive training in cultural competency. All contracted
providers and their subcontractors shall have a policy that pertains to cultural
competency.
The Michigan Department of Community Health (MDCH) and the United States Department
of Health and Human Services mandate that all supports and services will be provided in a
manner that demonstrates cultural competency. The culturally competent system of care
is developed based on utilization of several tools:
The assessment
The plan
Implementation of the plan.
Cultural Competency Guiding Principles as set forth below by Gateway are based on the
premise that a culturally competent program is one that is sensitive to, and
understanding of, cultural differences. Gateway requires that the implementation of an
understanding of and sensitivity to cultural differences are reflected in program
philosophy.
A consumer driven system of care promotes consumer and family as the most
important participants in service provision.
Natural community support and culturally competent practices are viewed as an
integral part of a system of care, which contributes to desired outcomes in a
managed care environment.
Culture is a predominant force in shaping behaviors, values and institutions;
Cultural differences exist and have an impact on service delivery.
Diversity is recognized and respected.
Unique, culturally defined needs of various consumer populations will be
respected.
71
Cultural Competence Standards: All contracted providers and subcontractors shall
develop a comprehensive cultural competence plan and integrate that plan into the
organizational structure that ensures attention to the following areas of practice:
The contracted providers and subcontractors shall have and demonstrate a
philosophy that reflect a comprehensive understanding of the dynamics of
ethnic and cultural differences and that provides a framework for eliminating
bias in service intervention and delivery.
It is recommended that the contracted provider‘s and subcontractor‘s mission
statement and goals recognize the cultural and ethnic diversity of the consumer
populations it services and reflect a commitment to serve those groups
sensitively and competently.
The contracted provider‘s and subcontractor‘s governing boards shall provide
overall guidance, and shall be accountable for the fulfillment of the Contractor‘s
mission, operations and the goals for the consumers it serves.
It is recommended the contracted provider‘s and subcontractor‘s board of
directors and/or advisory committee have representation and input from
individuals of different cultures and/or the ethnic groups reflective of the
community it serves.
The contracted provider‘s and subcontractor‘s board of directors shall have the
opportunity to learn about issues of cultural diversity and how those issues
effect the organization‘s contracted responsibility to provide high quality,
culturally competent services.
The contracted providers and subcontractors shall be knowledgeable about
federal, state, county and city laws and regulations that relate to culturally
diverse populations and address nondiscrimination policies and practices.
The contractor shall implement activities to obtain consultation from
organizations and/or outside experts that represent cultural and ethnic groups
in the community served before finalizing programs and policies that may
have cultural impact.
The contracted provider shall ensure that its program brochures, annual reports,
newsletters, special events, etc., reflect the diversity of the populations it
services.
Contracted provider documents, including policies and procedure manuals, shall
reflect recognition of the cultural diversity of its staff and the consumer
population it serves.
The contracted provider shall incorporate a community based system of care
which focuses on including familiar and valued community resources that are in
tune with the consumers cultural beliefs and consistent with their needs.
The contracted provider‘s outreach efforts and service delivery system shall
reflect responsiveness to the racial, cultural, and ethnic community it serves.
The contracted provider shall provide services that are geographically and
culturally accessible.
The contracted provider shall offer an avenue for the community it serves to
express their views, give feedback and exchange and let their needs be
articulated and included as an integral part of an on-going assessment of the
contracted network and the service delivery process.
72
The contracted provider shall actively advertise positions in culturally diverse
print and broad case media and through community information networks and
organizations representing culturally diverse groups.
The contracted provider shall document that staff are trained, provided continuing
education opportunities, and practice culturally congruent interventions.
The contracted provider shall have consistent opportunities for feedback and
exchange from consumers concerning service delivery.
Limited English Proficiency
Gateway ensures that no individuals are denied benefits or subjected to discrimination by
Gateway or contracted providers on the basis of limited English proficiency.
Interpretation: Refers to the spoken word interpreted from one language into another by
a third party.
Limited English Proficient (LEP): An individual who is unable to speak, read, write or
understand the English language at a level that permits him or her to interact effectively
with English speaking people.
Persons Eligible to be Served or likely to be Directly Affected: Are those people who are
in the entity‘s service area, and who either are eligible for the covered entities‘ benefits
or services, or otherwise might be directly affected by such an entity‘s conduct.
Safe Harbor: Written translations must be provided under the following circumstances:
Ensure that translated written material, including vital documents, are provided
for each eligible LEP language group that constitutes ten percent (10%) or
3000, whichever is less, of the population of persons eligible to be served, or
likely to be directly affected by the programs, services or supports required to
be provided by the network and contracted providers.
Ensure at minimum that vital documents are translated into the appropriate nonEnglish languages of persons for each LEP language group that constitute five
percent or 1,000 whichever is less, of the population of persons eligible to be
served, or likely to be directly affected by the programs, services, or supports
provided by the Network and contracted providers. Translation of other
documents, if needed, can be provided orally.
Ensure that written notice is provided in the primary language of the LEP language
group of the right to receive competent oral translation of written materials to
eligible LEP language groups that constitute less than 100 persons eligible to be
served, or likely to be directly affected by the programs, services, or supports
provided by Gateway and its contracted providers.
Service Area: The geographic areas, from which the Network and service providers
draw or can be expected to draw, consumers.
Translation: Refers to the written word, indicating materials written in one language and
translated into another.
73
Vital Documents: Includes applications or consent forms, letters or notices
regarding eligibility or participation criteria, and notices pertaining to reduction,
denial or termination of services or benefits, that require a response from
beneficiaries, and/or that advise regarding free language assistance. Large
documents such as enrollment books may not need to be translated in their entirety.
However, vital information contained in large documents must be translated.
Gateway and contracted providers shall:
Develop policies and procedures that accommodate individuals who have limited
proficiency.
Follow the Network‘s standards set in the Guidelines for Translations for MultiLanguage Materials or Products.
Ensure all services, programs, or activities shall be accessible and usable to
individuals with LEP.
Provide adequate information to enable individuals with LEP to understand the
types of services and benefits available.
Conduct a thorough assessment of the language needs of the service area, following
the federal safe harbor rules and identifying:
 The non-English languages that are likely to be encountered in its program
and estimate the number of LEP individuals that are likely to be directly served
by its program.
 The language needs of each client and record this information in the client‘s
record.
 The points of contact in the program or activity where language assistance is
likely to be needed.
 The resources that will be needed to provide effective language assistance
and the location and availability of these resources.
 The arrangement that must be made to access these resources in a timely
manner.
Provide a range of language assistance which may include:
 Sign
language
interpreters
for
individuals
with
hearing
impairments/limitations.
 Alternative formats such as large print or Braille for individuals with visual
impairments/limitations.
 Oral language interpretation for individuals that are non-English speaking.
 Hiring bilingual staff trained and competent in interpreting.
 Testing self-identified bilingual staff for language proficiency.
 Hiring trained and competent staff interpreters.
 Contracting with outside interpreter service(s) for training and competent
interpretation.
 Formally arranging for the services of trained and skilled voluntary community
interpreter(s).
 Arranging for the use of a telephone language interpreter service. This may
be used as a supplemental system or when a language encountered can not
be accommodated by other resources.
74
Ensure the interpreter service is familiar with terminology used in the provision of
mental health services.
Ensure that vital documents are available in language(s) other than English in
accordance with Federal safe harbor guidelines.
Ensure access by, at a minimum, providing notices in writing, in the LEP individual‘s
primary language, of the right to receive free language assistance in a language
other than English, including the right to competent oral translation of written
materials free of cost. Notice can be provided by, but not limited to:

Use of language identification cards, which allow LEP beneficiaries to
identify their language needs. A message on the card must invite the LEP
person to identify the language he/she speaks. Identification must be
included in the individual‘s record.
 Posting signs in regularly encountered languages (in accordance with
Federal safe harbor guidelines) other than English in waiting rooms,
reception areas, and other initial points of entry. These signs must inform
applicants and beneficiaries of their right to free language assistance
services and invite them to identify themselves as persons needing
services.
 Translation of applications and instructional information and other written
materials into appropriate non-English languages by competent
translators.
 Uniform procedures for timely and effective communication between staff
and LEP individuals. This includes instructions for English speaking
employees to obtain assistance from interpreters or bilingual staff when
receiving calls from, or initiating calls to LEP individuals.
 Inclusion of statements about services available and the right to free
language assistance services in applicable non-English languages, in
brochures, booklets, outreach, and recruitment information and other
materials routinely disseminated to the public.
Disseminate Limited English Proficiency policy to staff.
Provide training to new employees and periodic training to other staff to ensure
staff is:



Knowledgeable and aware of LEP policy and procedures.
Are trained to work effectively with interpreters.
Understand the dynamics of interpretation between consumers and the
interpreter
Monitor its language assistance program periodically to assess:





The current LEP makeup of its service area.
The current communication needs of LEP applicants and consumers.
Whether existing assistance is meeting the needs of such persons.
Whether staff is knowledgeable about policies and methods of
implementation.
Whether sources of arrangements for assistance are still current and viable.
75

If modifications are needed.
76
Section X
Grievance and Appeals
Introduction
It is the policy of Gateway that all consumers have the right to a fair and efficient
process for resolving complaints regarding their services and supports.
Purpose: To define appeals related to the actions of denial, reduction, suspension or
termination of services and supports; and grievances about any matter other than an
action, such as quality of care or relationships. To establish a structured grievance and
appeal resolution process for consumers that promotes the resolution of consumer
concerns, as well as support and enhance the overall goal of improving the quality of
care.
Grievance and Appeals
Grievance means an expression of dissatisfaction about any matter other than an
action. A grievance can be filed when a member of Gateway communicates dissatisfaction
with Gateway or the contracted service providers.
The Grievance and Appeals Coordinator is responsible for assuring effective
coordination of all disputes, grievances and appeals; tracking and trending the data;
assisting in the generation of regularly scheduled reports for review by the Executive
Director and MQC; and ensuring avoidance of conflict of interest or purpose related to
grievances, dispute, and appeals.
A grievance can be submitted orally or in writing by the member themselves, or their legal
representative. This can be done whenever a member verbalizes dissatisfaction. An
informal grievance can be a phone call or a letter to the service provider or to Gateway
Customer Service department at:
1-888-711-5465
Grievances may be filed 24 hours a day, 7 days a week
Gateway and the contracted providers shall ensure the informal grievance process is
initiated at the time a consumer is expressing dissatisfaction with services.
This process shall include the following:
Ensuring appropriate staff, who are not the subject of the grievance, immediately
resolve the consumer‘s concerns.
Ensuring professionals with the appropriate clinical expertise are consulted for all
grievances which involve clinical issues of medical necessity.
Logging of the date, time and resolution of the grievance.
Informing the consumer of his/her right to file a formal grievance, if the informal
grievance cannot be resolved.
77
A consumer may request assistance with their grievance from the service provider,
Gateway or other person of their choice. Persons in AFC facilities can be assisted in
completing the grievance form by their Case Manager and/ or their Service Provider or
their assigned representative.
There are interpreter and TTY/TTD services are available to help the consumer, if
needed.
Grievance forms must be available to all persons at Gateway service providers.
When the service provider or Gateway Community Health receives the grievance,
they must contact the complainant within one working day that their grievance
was received.
A letter titled ‗acknowledgement of grievance‘ must be sent confirming the receipt
of the grievance within 5 days of the actual grievance being filed. This letter will
come from the agency who received the grievance. The letter will specifically
come from Grievance and Appeals Coordinator, or Gateway Customer
Service staff. If the issue is moved to another department or supervisor, the
information will be referred back to the Grievance and Appeals Coordinator.
If the grievance is not resolved immediately the service provider or Gateway will
make a decision about the grievance within 30 calendar days from the day the
grievance was filed.
A notification of resolution letter must be sent upon resolution of the grievance.
The notification of the resolution letter will address other options that are available
to if the consumer is not satisfied with the resolution.
The whole grievance process should not exceed 60 days from the time the
grievance was filed.
Grievance information is kept separate from the consumer‘s clinical file.
Documentation of the grievance from the service providers must be sent to
Gateway‘s Grievance and Appeals Coordinator on a monthly basis by the 10th of
the following month. The information is then aggregated and sent to Detroit Wayne
County Community Mental Health Agency Grievance and Appeals Coordinator by
the 15th of every month.
78
Section XI
Recipient Rights
Introduction
Recipient Rights functions are the responsibility of the Detroit-Wayne County Community
Mental Health Agency.
All providers contracted with Gateway must have their employees trained in recipient
rights within 30 days from hire and annually thereafter. Providers are to contact the
Detroit- Wayne County Community Mental Health Agency‘s Office of Recipient Rights
at (313) 833-2500 to register staff for training.
Detroit-Wayne County Community Mental Health Agency Recipient Rights Policies can be
obtained by contacting the Agency‘s Office of Recipient Rights at (313) 833-2149 or at
www.gchi.org.
79
Section XII
Miscellaneous
[Remainder of page intentionally left blank]
80
GATEWAY COMMUNITY HEALTH
PRELIMINARY DEATH REPORT
Instructions:
All deaths must be reported to Gateway Community Health Inc. (GCHI) by telephone within one business day of notification at
the 24 hour number 1-800-973-4283. Do not fax, e-mail or leave a message. you must speak with someone. GCHI will provide
D-WCCMHA, ORR the information and obtain a Death Log Number.
Today’s Date:
Community Mental Health:
Type of Service:
Case Manager:
Consumer’s Name:
Gender:
Date of Birth:
Male
Female Age:
Date of Death:
Time:
Social Security #:
MCPN #:
Location of Death: _____________________________________ *City:
AFC Home: ______________________________________
Specialized or
Personal Home:
General
Yes
No
City:
Cause of Death (Check All That Apply):
Diabetes
Cancer
Heart Disease
Unknown at this time
Renal Failure
Stroke/Seizure
Infectious Disease
Other:
Was Death Expected?
Yes
No
Population:
MI Child
MI Adult
Was Adult/Child Protective Services Notified?
By Whom?
Yes
DD
No
Was Office of Children and Adult Licensing Notified?
By Whom?
Yes
No
Was Law Enforcement Notified?
By Whom?
Yes
No
AXIS I:
AXIS III:
Caller’s Name:
Telephone#:
Gateway Staff Name:________________________________
Telephone #:
* D-WCCMHA- ORR must have the city the consumer died in prior to giving a death log number to Gateway.
Gateway Quality Staff complete:
D-WCCMHA ORR Staff:
DL #:
Gateway Community Health
Quality Management Department
Revised 08/16/2010
81
REPORT OF RECIPIENT DEATH
(*MUST BE TYPED)
Date of Report:
Date of Death:
SECTION I:
Instructions:
(TO BE COMPLETED FOR ALL RECIPIENTS)
All deaths must be reported to the Agency's Office of Recipient Rights by telephone within one business day of
Provider notification.
This form and a copy of the Incident Report, if applicable, shall be mailed to the Agency's Office of Recipient
Rights within 10 business days of telephone notification.
If information is unavailable at the time the report is submitted, an amended report must be submitted.
SEND THE LAST 3 PSYCHIATRIST, THERAPIST, CASE MANAGEMENT PROGRESS NOTES AND INDIVIDUAL
PLAN OF SERVICE ALONG WITH THIS REPORT. PLEASE FAX THE REPORT AND DOCUMENTS TO QUALITY
COMPLIANCE SPECIALIST AT 313-263-2513 OR 313-263-2453
1. Service Provider: __________________________ 2. Provider No.: ____________________________________
3. Client Name: ______________________________ 4. D-WCCMHA Case Number: _________________________
5. Place of Death: [ ] Detroit [ ] Other Wayne County:
6. Social Security Number: _____________________ 7. Sex: _____ 8. Race: _____ 9. Birth Date: ______________
10. Program(s) in which client was active at time of death:
Inpatient ] A.C.T.
Outpatient
Substance Abuse
Residential
Partial Day
a) Admission Date: __________
Other (specify)
b) Population: MI
MI Child
DD
11. Was the Treatment Plan developed by an Interdisciplinary Team?
Yes
] No
12. Was the client hospitalized in a state facility within the past six months?
Yes
No If yes, name of facility
Discharge Date:
13. Date of client's last treatment by Provider: ________________ ________________________________________
14. When was death discovered by Provider? (date and time): ______________ _____________________________
15. When did death occur? (date and time): _______________ __________________________________________
16. Where did death occur? ___________________________________ __________________________________
(Location, including place and city)
17. Was the death expected?
or unexpected?
18. Brief explanation of death: (If Incident Report was completed, please attach):
(Attach extra sheets if needed.)
82
REPORT OF RECIPIENT DEATH
(*MUST BE TYPED)
SECTION II:
1. Current DSM Diagnosis (include all 5 Axis):
A. AXIS I:
AXIS II:
AXIS III:
AXIS IV (Specify Stressor(s), State Severity:
AXIS V GAF:
B. Alcohol/Substance Use: Write Diagnosis on AXIS I or AXIS III.
If NONE, CIRCLE ―NONE‖ HERE
2. CAUSE OF DEATH:
3. RELEVANT
PAST
MEDICAL
HISTORY
INCLUDING
MOST
RECENT
MED/SURG
HOSPITALIZATION:
4. SUMMARY OF PSYCHIATRIC TREATMENT INCLUDING MOST RECENT PSYCHIATRIC
HOSPITALIZATION, INCLUDING DATES:
83
5. SURGICAL PROCEDURES DURING PAST YEAR:
6. RECENT CHANGES IN MEDICAL STATUS:
7. SUMMARY OF MEDICAL CONDITION AND TREATMENT PRECEDING DEATH (IF TREATED IN A
MEDICAL/SURGICAL FACILITY. INCLUDE DATE OF ADMISSION AND DISCHARGE):
8. MEDICATIONS (DOSE AND TIME ADMINISTERED):
(A) LAST 24 HOURS
(B) LAST 30 DAYS
9. CIRCUMSTANCES SURROUNDING DEATH, INCLUDING TREATMENT (Attach extra sheets if
needed)
Physician and/or Preparer‘s Signature and Telephone Number
(If psychiatrist is on staff, physician‘s signature must be included)
84
REPORT OF RECIPIENT DEATH
(*MUST BE TYPED)
This page is being requested by a Gateway Community Health physician and Quality staff for the
purposes of more in depth analysis of possible trends related to consumer deaths.
SECTION III:
Any Medical Condition:
Yes
No
Did consumer have a Primary Care Physician?
Yes
No
Name of PCP:
Dates of contact with PCP in last 90 days?
______________________________________________
Was the consumer compliant with psychotropic and medical medications in the past 30 days?
Weight:
lbs.
Was the consumer a Smoker?
/km
Yes
Yes
No
Height: __________ Ft. __________ Inches
No
How many packs a day? ______________ (approximate)
Did the consumer abuse Alcohol?
Yes
No
Did the consumer abuse drugs other than alcohol?
How often did the consumer drink?
Yes
No
How long?
Name of Substance(s) used?
Did consumer ever participate in Outpatient Substance Abuse Treatment including AA/NA?
Yes
No
Which Program?
SEND THE LAST 3 PSYCHIATRIST, THERAPIST, CASE MANAGEMENT PROGRESS NOTES AND INDIVIDUAL
PLAN OF SERVICE ALONG WITH THIS REPORT. PLEASE FAX THE REPORT AND DOCUMENTS TO QUALITY
COMPLIANCE SPECIALIST AT 313-263-2513 OR 313-263-2453.
85
GATEWAY COMMUNITY HEALTH
REPORTABLE SENTINEL EVENT FORM
Sentinel Events must be reported by telephone or e-mail to Gateway‘s Quality Unit
within one (1) business day. If you complete and send the Sentinel Vent Form within
one (1) business day, you do not need to make the phone call or send the e-mail. To
report by telephone, please call L.C. Smith at (313) 263-2452. If you do an e-mail
notification, please e-mail lsmith@gchi.org.
This form must be typed, completed and submitted to Gateway‘s Quality Unit within
three (3) business days of the notification. Fax this form to Gateway Community Health,
Quality Manager – Special Programs, at (313) 263-2453.
Initial Report
Updated Report
1. Date of Report:
2. Date of Occurrence:
3. Name of MCPN/Service Provider:
Gateway Community Health/
4. Name of Person Receiving Services:
5. Is the person registered in CMH-Link?
Yes
No – Member ID#:
6. Date of Birth:
7. Social Security#:
8. Setting:
Habilitation Support Waivers Services
Targeted Case Management
Supports Coordination
Own Home w/Community Living Supports
Children‘s Waiver
Substance Abuse Residential Treatment Program
ACT Program
Home Based Program
Wraparound Program
Specialized Residential and/or Child Caring Institution
(fill out lines below)
Name of AFC or CCI:
MDHS License#:
86
9. Type of Incident:
Injuries that require ER visits, medi-center, urgent care clinics/centers and/or
admission(s) to hospital(s) as a result of an incident resulting from abuse, neglect
or accidents or loss of limb or function
Arrest of recipient
Conviction of recipient
Death of recipient that did not occur as a result of the natural outcome to a
chronic condition or old age
Medication error(s) (wrong medication, wrong dosage, double dosage, or missed
dosage resulting in risk of harm or adverse reaction(s) or the risk thereof)
Physical illness requiring admission(s) to a hospital(s) (do not include planned
surgeries, whether inpatient or outpatient OR admissions directly related to the
natural course of the person‘s chronic illness or underlying condition)
Serious challenging behaviors not already addressed in the IPOS (include
property damage> $100.00, attempts at self-inflicted harm or harm to others, or
unauthorized leaves of absence)
10. Detail Summary of Review:
11. Detail Summary o Findings/Decision:
12. Detail Summary of Action(s) Taken:
13. Detail Summary of Follow-up:
Print Name of Staff Completing Report:
Signature:
Phone#:
Fax#:
Cellular Phone#:
Date:
E-Mail:
Pager#:
87
Glossary
Priority of Application. The definitions of terms contained in this glossary are general
definitions that take precedence over any competing or ―common‖ meaning in every
instance in which such term is capitalized in any document or correspondence, with the
exception that:
(a) Any such general definitions shall be subordinate to and replaced by any conflicting
definitions contained in Gateway‘s, MCPN or other contracts, extensions, or
expansions, the Michigan Mental Health Code, Medicaid regulation, MDCH or
DWCCMHA written policy or procedure, to the extent that such definitions have
been incorporated or are otherwise legally applicable to the topic addressed in any
document or correspondence; and
(b) Both the general and incorporated definitions referred to above shall be
subordinate to and replaced by any specific definitions included in a particular
text in any document or correspondence, and such case specific definitions
shall take precedence over any competing general or incorporated definitions of
such terms in those instances.
To assist in understanding the context in which and sources from which these
definitions were derived, when these definitions remain identical to those in the source
materials, this is indicated by referring to that source in parenthesis.
Acute Crisis Intervention Home - Short-term services provided in a protected residential
setting under the supervision of a Qualified Mental Health Professional for developmentally
disabled adults who also have mental illness and are experiencing an acute
exacerbation of the illness. (DWCCMHA/MCPN Contract)
Administrative Efficiencies - The ability to produce a desired effect in with a minimum of
effort, expense, or waste as applied to management functions of the organizations.
(DWCCMHA/MCPN Contract)
Administrative Fair Hearing or Medicaid Fair Hearing - An impartial review process
maintained by the MDCH to ensure that Medicaid beneficiaries or their legal
representatives involved in a community Mental Health Services Program have the
opportunity to appeal decisions of DWCCMHA or its representatives which result in the
denial, suspension, reduction or termination of Medicaid covered services. A Medicaid
beneficiary or any person entitled to services may request a hearing within 90 days of
notice of the denial, suspension, reduction or termination of Medicaid-covered benefits.
(DWCCMHA/MCPN Contract)
88
Administrative Request for Reconsideration - Any written dissatisfaction or
disagreement by a provider following an adverse decision of a Provider Dispute and a
desire to appeal the dispute to the next level, if permitted by Gateway and/or Consumer,
as applicable. (Operations)
Adult Foster Care Home - (Adults Ages 18 and Older) Adult Foster Care is a general
licensed living arrangement that may accommodate one or more residents. Residents
in this setting have mild to no maladaptive behaviors and may or may not require
assistance with community living and self care tasks. Specialized services can be
arranged and provided in this setting if indicated. (DWCCMHA/MCPN Contract)
Adverse Action - A denial, suspension, reduction or termination of mental health services,
except as ordered by a physician's determination of absence of medical necessity.
(DWCCMHA/MCPN Contract)
AFP - MDCH's required Application for Participation. (DWCCMHA/MCPN Contract)
Appeal – In relation to recipient rights, a process established by MDCH to provide a
mechanism for prompt reporting, review, investigation, and resolution of apparent or
suspected violations of the rights guaranteed by the Michigan Mental Health Code.
(MMHC)
Assertive Community Treatment (ACT) - Assertive Community Treatment (ACT) is a
comprehensive and integrated set of medical and psychosocial services provided on
a one-to-one basis primarily in the client's residence or other community locations
(non- office setting) by a mobile multidisciplinary mental health treatment team. The
team provides an array of essential treatment and psychosocial interventions for
individuals who would otherwise require more intensive and restrictive services. The
team provides additional services essential to maintaining an individual's ability to
function in community settings. This would include assistance with addressing basic
needs, such as food, housing, and medical care and supports to allow individuals to
function in social, educational, and vocational settings. (DWCCMHA/MCPN Contract)
Authorization - A decision rendered by a Qualified Professional who has been
delegated the authority by Gateway, to approve a request for covered clinical services as
meeting the criteria of Medical Necessity. (DWCCMHA/MCPN Contract)
Authorized Representative - An authorized representative is any individual
designated by a member or appointed by a court to represent his or her interest,
including but not limited to, a practitioner, spouse, parent, family member, or legal
representative (such as a guardian, executor or attorney). (MMHC and Operational
P&P)
Authorized Services - Services deemed medically necessary and eligible for
reimbursement based on the contract between the provider and the Network.
89
All funded services are authorized by Gateway, but only a specific subset of available
services require prior authorization. (Operational P&P)
Beneficiary - Persons who are Medicaid-eligible. (DWCCMHA/MCPN Contract)
Best Value - A process used in competitive negotiated contracting to select the most
advantageous offer by evaluating and comparing factors in addition to cost or price.
(DWCCMHA/MCPN Contract)
Capitation - Generally: a fixed amount paid per month for covered services to be
provided to each member of a referenced class of eligible recipients for whom such
services are medically necessary. (Operational) As applied to DWCCMHA/MCPN
contracts: A fixed amount paid per month per Person to the MCPN for Covered
Services. (DWCCMHA/MCPN Contract)
Categorical Funds - Funds that are designated for a specific service, program and/or
special population. (DWCCMHA/MCPN Contract)
CCH -Contracted Community Hospital that provides acute inpatient and/or partial
hospitalization services by contract with DWCCMHA. (DWCCMHA/MCPN Contract)
Certification - Certification is a process of evaluating/screening clients to determine and
approve appropriate and clinically necessary services for inpatient psychiatric admission,
and other prior authorized services, which includes certifying appropriateness of all
inpatient hospital and physician services related to the admitting mental health diagnosis,
including laboratory and x-ray services, medications, etc. Any inpatient psychiatric
admission not certified by the CMH is not a benefit of the Medicaid program.
(DWCCMHA/MCPN Contract)
CFAC -Consumer Family Advocate Council (DWCCMHA/MCPN Contract)
CAFAS - Child and Adolescent Functional Assessment Scale (DWCCMHA/MCPN
Contract)
Child Mental Health Professional - One of the following: a) A person who is trained
and has one year of experience in the examination, evaluation, and treatment of
minors and their families and who is one of the following: i. A physician ii. A psychologist
iii. A certified social worker or social worker; iv. A registered nurse; OR b) A person
with at least a bachelor's degree in a mental health-related field from an accredited
school who is trained, and has three (3) years of supervised experience, in the
examination, evaluation, and treatment of minors and their families. OR c) A person with
at least a master's degree in a mental health-related field from an accredited school who
is trained and has one year of experience, in the examination, evaluation, and treatment
of minors and their families. (DWCCMHA/MCPN Contract)
90
Children's Diagnostic and Treatment Service - A program operated by or under
contract with a Community Mental Health Services Program, which provides
examination, evaluation and referrals for minors, including emergency referrals, that
provides or facilitates treatment for minors, and that has been certified by MDCH.
(DWCCMHA/MCPN Contract)
Clean Claim -A clean claim is one that can be processed in accordance with the claims
processing requirements specified in the Provider Manual without obtaining additional
information from the provider of the service or a third party. It does not include a claim
from a provider who is under investigation for fraud or abuse, or a claim under
review for medical necessity. (Operations; DWCCMHA/MCPN Contract)
Clinical Appeal - A request by a member, member-designated representative, or
provider to review an adverse medical necessity determination made in response to a
request for services. The Clinical Appeal process is described in the Provider Manual.
(Operations)
CM - Case Manager/qualified primary case manager (DWCCMHA/MCPN Contract)
CMH - Community Mental Health (DWCCMHA/MCPN Contract)
CMHP - Child Mental Health Professional (DWCCMHA/MCPN Contract)
CMS - Centers for Medicare and Medicaid Services (DWCCMHA/MCPN Contract)
Community Mental Health Services Program (CMHSP) - A program operated under
Chapter 2 of the Michigan Mental Health Code – Act 258 of 1974 as amended.
Complaint - An oral or written statement made to the Office of Recipient Rights ("ORR")
alleging violation of a Mental Health Code protected right. (DWCCMHA/MCPN Contract)
Consumers - Recipients of services designated by two types: Primary and Secondary.
Primary refers to the recipient of services. Secondary refers to family members of the
primary recipient. (DWCCMHA/MCPN Contract)
Co-Occurring Disorders - When used in the context of Persons, this term refers to cooccurring psychiatric and/or substance use disorders. (DWCCMHA/MCPN Contract)
Contracted Provider - An individual or entity participating in the Provider Network pursuant
to a contract with Gateway to provide Covered Services. (DWCCMHA/MCPN Contract)
91
Corrective Action Plan (CAP) - Refers to the written plan of action that a provider has
been formally required by Gateway to develop/take to address/answer deficiencies
formally identified as constituting material breaches of its contractual obligations. There
are two applications of the term.
It can refer either to (a) the Plan required to be developed and submitted by the provider
for approval by Gateway or (b) a specific Plan directed by Gateway. A Corrective Action
Plan will generally:
1. Address how corrective action will be accomplished for those enrollees and
entities affected by the deficient performance/practice;
2. Address how the provider will identify other enrollees having the potential to be
affected by the deficient performance/practice;
3. Address what measures will be put into place or systemic changes made to
ensure that the deficient performance/practice will not recur;
4. Indicate how the provider plans (or, if a directed POC, how the provider will be
required) to monitor its performance/practice to make sure that solutions are
sustained.
5. Include dates when corrective action(s) will be completed.
Covered Services under MCPN - Contract Specialty supports and services as
described in Appendix B of DWCCMHA/MCPN contract, as amended.
(DWCCMHA/MCPN Contract)
Credentialing - The review process used by Gateway to determine if a practitioner, group,
group or facility that has applied to participate in a provider network meets criteria for
inclusion. This review process is described in the Gateway Manual (Operations)
Crisis Residential (CR) - Short term intensive treatment services provided in a protected
residential setting as an alternative to inpatient hospital admission when clinically
appropriate for people experiencing acute psychiatric crisis diagnosed by a Qualified
Mental Health Professional, as meeting criteria for an acute inpatient hospital
admission. The mentally ill adult must have symptoms that can be stabilized in an
alternative community setting. (DWCCMHA/MCPN Contract)
Cultural Competency - The capacity of the network to address behavioral health needs of
members in a manner that is congruent with their cultural, religious, ethnic, and linguistic
backgrounds. A set of academic and interpersonal skills that allow individuals to
increase their understanding and appreciation of cultural differences and similarities
within, among, and between cultural groups. This requires a willingness, and ability
to draw on community-based values, traditions, and customs, and to work with
knowledgeable individuals of, and from, the community in developing targeted
interventions, communications and other supports to address the unique needs of
specific population groups.
92
An acceptance and respect for difference, a continuing self-assessment regarding culture,
a regard for and attention to the dynamics of difference, engagement in ongoing
development of cultural knowledge, and resources and flexibility within service models
to work toward better meeting the needs of the minority populations. The cultural
competency of an organization is demonstrated by its policies and practices.
Customers In this Agreement, a potential recipient of Covered Services, which includes
all people located in the defined service area. (Operations; DWCCMHA/MCPN
Contract)
Denial of Authorization - An adverse decision made by a psychiatrist regarding a
request to authorize services, after appropriate evaluation of relevant clinical
information. (DWCCMHA/MCPN Contract)
Department of Human Services – DHS formerly FIA
Dependent Living Setting - An Adult Foster Care facility b) A nursing home c) A
Home for the Aged d) Child Caring Institution (DWCCMHA/MCPN Contract)
Detroit-Wayne County Community Mental Health Agency (DWCCMHA) - The
community mental health services program established and administered pursuant to
provision of the State Mental Health Code, for the purpose of providing a
comprehensive array of mental health services appropriate to the condition of
individuals who are Wayne County residents, regardless of ability to pay.
(DWCCMHA/MCPN Contract)
Duplicate Claim - A claim with the same member number, date of service, provider and
service/procedure as a previously paid claim. (Operations)
Early On Program - Early On services are delivered to children ages 0 to 3
identified either with a developmental delay or developmental disability. Early On
services provide infant mental heath services to families with children between the ages
of 0 to 3, who have been identified as "at risk" for an out of home placement due to
parenting problems such as substance abuse, mental illness, physical abuse, or
neglect. Additional services include clinic-based and home-based services for children
between the ages of 3 to 5. These services shall be designed and delivered in such a
manner as a) to provide an aftercare option for children who were discharged from
Early On services or infant mental health services due to reaching the age limitation; b)
to provide a transitional option for children who were discharged from Early On
services or infant mental health services due to achieving their treatment goals; c) to
provide services to families with children ages 3 to 5, who have been identified as "at
risk" for an out-of-home placement due to parenting problems such as substance
abuse, mental illness, physical abuse or neglect. (DWCCMHA/MCPN Contract)
93
Effective Freedom - The realization of social citizenship and full community membership.
Citizens are able to build upon basic freedoms – to effectively unlock the potential of
liberty – by making choices, pursing personal goals, engaging in productive activity,
establishing a wide range of associations and relationships, participating in
community events, and living in real homes. (DWCCMHA/MCPN Contract)
Emergency Situation - A situation in which an individual is experiencing a serious
mental illness or a developmental disability, or a child is experiencing a serious
emotional disturbance, and one of the following apply: 1. The individual can reasonably
be expected within the near future to physically injure himself, herself, or another
individual, either intentionally or unintentionally.
2. The individual is unable to provide himself or herself food, clothing, or shelter, or to
attend to basic physical activities such as eating, toileting, bathing, grooming, dressing,
or ambulating, and this inability may lead in the near future to harm to the individual or
to another individual. 3. The individual's judgment is so impaired that he or she is
unable to understand the need for treatment and, in the opinion of the mental health
professional, his or her continued behavior as a result of the mental illness,
developmental disability, or emotional disturbance can reasonably be expected in the
near future to result in physical harm to the individual or to another individual.
(DWCCMHA/MCPN Contract)
Encounter -A face to face meeting between a covered person and health care
provider where services are delivered. (Operations) A document submitted in a
claim format specified by DWCCMHA that documents the services and costs of services
provided to a consumer. (DWCCMHA/MCPN Contract)
Enhanced Health Services - Those services beyond the responsibility of the
Person's health plan, that are provided for rehabilitative purposes to improve the
Person's overall health and ability to care for health-related needs. This includes nursing
services, dietary/ nutrition services, maintenance of health and hygiene, teaching selfadministration of medication, care of minor injuries or first aid, and teaching the Person
to seek assistance in case of emergencies. Services must be provided according to
the professional's scope of practice and under appropriate supervision. Enhanced health
services must be carefully coordinated with the Person's health care plan.
(DWCCMHA/MCPN Contract)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) - Federal
regulations require state Medicaid programs to offer early and periodic screening,
diagnosis, and treatment (EPSDT) to eligible Medicaid beneficiaries under 21 years of
age. The intent is to find and treat problems early so they do not become more serious
and costly. (DWCCMHA/MCPN Contract)
94
Executive Performance Oversight Committee (EPOC) - An internal committee
tasked with reviewing the performance of contract providers against their contractual
performance standards and recommending appropriate provider sanctions for
noncompliance with contractual, policy, or procedural issues and issues related to
member complaints/grievances, Recipient Rights violations, quality of care, or
complaints of violations of state and federal laws and regulations. (Operations)
Explanation of Benefit (EOB) - A statement mailed to providers explaining why a
claim was or was not paid. (Operations)
Facility - A residential building for the care or treatment of individuals with serious
mental illness, serious emotional disturbance, or developmental disability that is
either a state facility or a licensed facility. (DWCCMHA/MCPN Contract)
Fee for Service (FFS) – A form of reimbursement for health care services in which a
provider is paid a specific amount for a service rendered. (Operational)
FIA - Family Independence Agency (DWCCMHA/MCPN Contract)
Grievance - A process for expressing dissatisfaction with an actual or supposed
circumstance regarded by the complainant as just cause for protest about mental health
treatment/services/supports, managed and/or delivered by DWCCMHA network, made in
accordance with the Mental Health Code, with available assistance of an ORR
representative, as needed. (DWCCMHA/MCPN Contract)
HCFA- Health Care Financing Administration, now known as the Centers for Medicare and
Medicaid Services. (DWCCMHA/MCPN Contract)
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Public Law
104- 191, 1996 to improve the Medicare program under the Title XVIII of the Social
Security Act, the Medicaid program under the Title XIX of the Social Security Act, and
the efficiency and effectiveness of the health care system, by encouraging the
development of a health information system through the establishment of standards
and requirements for the electronic transmission of certain health information. The
Act provides for improved portability of health benefits and enables better defense
against abuse and fraud, reduces administrative costs by standardizing format of specific
healthcare information to facilitate electronic claims directly addresses confidentiality
and security of patient information – electronic and paper-based, and mandates "best
effort" compliance. HIPAA mandates, among others, that the following requirements
must be implemented: 1- Data integrity, confidentiality, and availability guards. 2Access control (user-based, role-based, and availability). 3- Audit controls (user-based,
role-based). 4- Data authentication (automatic log-off, unique user ID, password, PIN,
biometrics, token, or telephone callback). 5- Unauthorized access guards 6Communications/network controls (access controls, encryption, integrity controls or
message authentication)
95
7- Network controls (alarm, audit trail, entity authentication, event reporting, userbased, role-based, or context based access) (DWCCMHA/MCPN Contract)
Individual - For the purpose of the DWCCMHA/MCPN contract, sub-contracts, and
provider contracts: a person with mental illness, developmental disabilities, or
substance use disorders (or a combination of disabilities), including persons who are
Medicaid- eligible, as well as other mental health and substance abuse specialty
services recipients who may be indigent, are self-pay, or have private insurance
coverage. (DWCCMHA/MCPN Contract)
Initial Assessment -Term used in substance abuse service. It is a process that collects
sufficient information to determine a level of care based on at least the six dimensions
of the American Society of Addiction Medicine Patient Placement Criteria. This initial
assessment process also gathers enough information to determine an initial diagnostic
impression using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
(DWCCMHA/MCPN Contract)
Intensive Crisis Stabilization -The process of stabilizing an individual in acute crisis to
avert a psychiatric admission or to shorten the length of an inpatient stay.
(DWCCMHA/MCPN Contract)
Intensive Crisis Stabilization Services - Structured treatment and support activities
provided by a mental health crisis team, under psychiatric supervision and designed to
provide a short-term treatment alternative to inpatient psychiatric services. Services
should be used to avert a psychiatric admission or to shorten the length of an inpatient
stay. (DWCCMHA/MCPN Contract)
IPOS -Individual Plan of Service (DWCCMHA/MCPN Contract)
ITT- Interdisciplinary Treatment Team (DWCCMHA/MCPN Contract)
I-Team - Agency Inter-Divisional Team (DWCCMHA/MCPN Contract)
Jail Diversion – Is a collaborative, integrated program utilizing a community's resources
to divert a person with serious mental illness, serious emotional disturbance or
developmental disability from possible jail incarceration when appropriate.
(DWCCMHA/MCPN Contract)
Length of Stay (LOS) - The number of days that a member remains in a given level of
care. (Operations)
Level of Care (LOC) - The intensity of professional care required to achieve the treatment
objectives for a specific episode of care. (Operations)
96
Level of Care (LOC) DWCCMHA/MCPN Contract Protocols - Severity of
Illness/Intensity of Service Protocols provided by the Michigan Department of Community
Health ("MDCH") and DWCCMHA, each as amended from time to time, as part of a
utilization management system, which are intended to monitor the appropriateness of
mental health care. Severity of Illness refers to the nature and severity of the signs,
symptoms, functional impairments, and risk potential related to the person's complaint.
Intensity of Service pertains to the setting of care, to the types and frequency of needed
services and supports, and to the degree of restriction necessary to safely and effectively
treat the individual. (DWCCMHA/MCPN Contract)
Limited English Proficiency (LEP) - Persons, who cannot speak, write, read or
understand the English language in a manner that permits them to interact effectively with
health care providers and social services agencies. (DWCCMHA/MCPN Contract)
Linguistically Appropriate Services - Provided in the language best understood by the
consumer through bi-lingual staff and the use of qualified interpreters, including
American Sign Language, to individuals with limited-English proficiency. These services
are a core element of cultural competency and reflect an understanding, acceptance,
and respect for the cultural values, beliefs, and practices of the community of
individuals with limited- English proficiency.
Linguistically appropriate services must be available at the point of entry into the
system and throughout the course of treatment, and must be available at no cost to the
consumer. (DWCCMHA/MCPN Contract)
MACMHB - Michigan Association
(DWCCMHA/MCPN Contract)
of
Community
Mental
Health
Boards
Medicaid Abuse - This term, generally used in the context of Medicaid Fraud and
Abuse, refers to provider practices that are inconsistent with sound fiscal, business or
medical practices, and result in an unnecessary cost to the Medicaid program, or in
reimbursement for services that are not medically necessary or that fail to meet
professionally recognized standards for health care. It also includes recipient practices
that result in unnecessary cost to the Medicaid program (42 CFR § 455.2).
Medicaid Verification - The process described in the Provider Manual to verify that
claims have been filed in accordance with all applicable federal and state legal
requirements and any applicable local standards.
MCO - Managed Care Organization (DWCCMHA/MCPN Contract)
MCPN - Manager of a comprehensive provider network contracting with DWCCMHA. For
each Manager of Comprehensive Provider Network Contract, MCPN shall include all
parties to such agreement other than DWCCMHA. (DWCCMHA/MCPN Contract)
97
MCPN Manual -The manual developed and implemented by DWCCMHA, and adopted
by the MCPN, that includes policies, procedures, forms, instructional materials, and
other information as referenced and incorporated by individual provider contracts with
Gateway and used to support and supervise/manage the Provider Network, in
accordance with Agency guidelines. (DWCCMHA/MCPN Contract)
MDCH - Michigan Department of Community Health, State of Michigan. The State
division is responsible for funding a comprehensive array of specialty mental health
services for persons with serious mental illness and children with severe emotional
disturbances and specialty services for persons with developmental disabilities and to
priority populations as defined in the Michigan Mental Health Code. (DWCCMHA/MCPN
Contract)
Management Services Council - A committee (however denoted) established by
DWCCMHA in accordance with the terms of the DWCCMHA/MCPN contract, comprised
of key Agency executives, to manage the Agreement between DWCCMHA and the
MCPN. (DWCCMHA/MCPN Contract)
Medicaid Eligible – An individual who has been determined to be eligible for Medicaid
by the State of Michigan. (DWCCMHA/MCPN Contract)
Medical Necessity -The clinical appropriateness of a course of treatment/ specific
services suitable to the patient's need, based on the client's psychiatric status using
approved clinical criteria and professional judgment. As defined by the MDCH, medical
necessity refers to mental health and/or substance abuse services that are: 1.
Necessary for screening and assessing the presence of a mental illness or substance
(use) disorder, as defined by standard diagnostic nomenclature (i.e., DSM-IV or its
successor); 2. Required to identify and evaluate a mental illness or substance (use)
disorder that is inferred or suspected; 3. Intended to treat, ameliorate, diminish, or
stabilize the symptoms of mental illness (or substance use) disorder and to prevent or
delay relapse; 4. Expected to prevent, arrest or delay the development or
progression of a mental illness (or substance use disorder) to prevent or delay
relapse; 5. Designed to provide rehabilitation for the recipient to attain or maintain an
optimal level of functioning according to his or her potential, (including functioning in
important life domains, such as daily activities, social relationships, independent living,
and employment pursuits); 6. Delivered consistent with national professional standards of
practice, including standards of practice in community psychiatry, psychiatric
rehabilitation and in substance abuse services, and/or empirical professional
experience; 7. Provided in the least restrictive setting. (DWCCMHA/MCPN Contract)
Mental Health Professional - A person who is trained and experienced in the areas of
mental illness or mental retardation and who is any one of the following: 1) A physician
who is licensed to practice medicine or osteopathic medicine in Michigan and who has
substantial experience with mentally ill or developmentally disabled recipients for one year
immediately preceding his/her involvement with a recipient under these rules;
98
2) A psychologist 3) A certified social worker 4) A registered nurse 5) A professional
person, other than those defined in these rules, who is designated by the director in
written policies and procedures. This mental health professional shall have a degree
in his or her profession and shall be recognized by his or her respective professional
association as being trained and experienced in the field of mental health.
(DWCCMHA/MCPN Contract)
Michigan Department of Consumer and Industry Services (MDCIS) - The State
agency responsible for licensure and certification of Adult Foster Care (AFC) homes.
(Michigan Code)
MIChild - A health insurance program offered through the State of Michigan for the
uninsured children of Michigan's working families; eligibility requirements are established
by the State. (DWCCMHA/MCPN Contract)
MRS - Michigan Rehabilitation Services, now known as the Michigan Department of
Career Development—Rehabilitation Services. (DWCCMHA/MCPN Contract)
Multicultural Services -Specialized mental health services for multicultural
populations such as African-Americans, Hispanics, Native Americans, Asian and Pacific
Islanders, and Arab/Chaldean-Americans. (DWCCMHA/MCPN Contract)
Non-Categorical Funds - Funds that are not designated for any specific programs,
services or special populations. (DWCCMHA/MCPN Contract)
OBRA - Omnibus Budget Reconciliation Act of 1987; 1990 is federally mandated
legislation establishing programs and a funding program that was developed in 1989.
Office of Recipient Rights (ORR) - Division of DWCCMHA established in
accordance with the Michigan Mental Health Code to ensure a uniformly high standard
of protection of the rights of the recipients throughout the State. (DWCCMHA/MCPN
Contract)
Out-of-Area Services -These are services provided to Wayne County consumers by
out-of-area service providers who are not part of the Detroit-Wayne County Community
Mental Health Network. Typically, special "purchase of service" arrangements are
negotiated with the out-of-area provider or responsible CMHSP for that area, to
provide the service(s). While DWCCMHA's MCPNs are expected to have a countywide
network, there may be occasions when the MCPN may need to secure such service
provisions as out-of-area on a temporary time targeted basis. There are times when
such services may have to be obtained out of state, however, these out-of-area and out of
state services will need to be authorized, paid and monitored by the MCPN.
Transportation should be provided when necessary. (DWCCMHA/MCPN Contract)
99
Out-of-Network Services - Services provided by a mental health professional who does
not participate in the Provider Network. (DWCCMHA/MCPN Contract)
Outreach - Efforts to extend services to those Persons who are under-served or hard-to
reach that often require seeking individuals in places where they are most likely to be
found, including hospital emergency rooms, homeless shelters, women's shelters, senior
centers, nursing homes, primary care clinics and similar locations. (DWCCMHA/MCPN
Contract)
Participating (PAR) Provider - A participating (PAR) provider has an agreement with
GATEWAY and/or its affiliated companies to provide mental health to Gateway members.
Unless otherwise specified, in this policy the term PAR provider refers not only to
institutions, but also to PAR individual professionals. (Operational P&P)
PASARR - readmission screening and annual resident review are requirements of the
OBRA program. Preadmission screening must be completed prior to placement of a
person with mental illness in nursing homes. Annual review determines the need for
continued nursing home care and whether specialized services for the mental illness are
indicated. (DWCCMHA/MCPN Contract)
Person - For the purpose of the DWCCMHA/MCPN contract, sub-contracts, and provider
contracts, Person is an Individual with Serious Mental Illness/Severe Emotional
Disturbance who qualifies for Covered Services and selects MCPN for such services.
(DWCCMHA/MCPN Contract)
Person-Centered Planning or PCP - Process for planning and supporting an individual
receiving service that builds upon the individual's capacity to engage in activities that
promote community life and that honor the individual's preferences, choices, and abilities
through the Public Mental Health System. The person-centered planning process involves
families, friends, and professionals as the individual desires or requires.
(DWCCMHA/MCPN Contract)
Policy Manuals of the Medical Assistance Program - The MDCH periodically issues
notices or proposed policy for the Medicaid program. Once a policy is final, MDCH issues
policy bulletins that explain the new policy and give its effective date. These documents
represent official Medicaid policy and are included in the policy manual of the Medical
Assistance Program. (DWCCMHA/MCPN Contract)
Practice Guideline - MDCH-developed guidelines for PIHPs for specific service,
support or systems models of practice that are derived from empirical research and
sound theoretical construction and as applied to the implementation of public policy.
MDCH guidelines issued prior to June 2000 were called "Best Practice Guidelines." All
guidelines are now referred to as Practice Guidelines. (DWCCMHA/MCPN Contract)
100
Prepaid Inpatient Health Plan (PIHP) - Organization that manages specialty health care
services under the Michigan Medicaid Waiver Program for Specialty Services.
(DWCCMHA/MCPN Contract)
Priority Population - Persons who are at risk for developing serious emotional
disturbance (SED) serious mental illness (SMI) or have developmental disabilities (DD).
For purposes of managing specialized treatment and support services, SMI and SED are
defined by diagnosis, degree of disability and/or duration of illness. (DWCCMHA/MCPN
Contract)
Protected Health Information (PHI) – Is individually identifiable health information that is
maintained or transmitted by a ―HIPAA covered‖ entity in any form or medium.
Information is considered to be ―individually identifiable‖ if (i) it identifies the individual or
(ii) there is a reasonable basis to believe that the information can be used to identify the
individual. In addition to clinical information, individually identifiable health information
may include demographic characteristics, such as name, address, age, or payment and
billing details such as procedure code and diagnosis. (HIPAA)
Provider - A legal entity or independent practitioner that provides covered services and
supports as specified by Gateway. (DWCCMHA/MCPN Contract)
Provider Applicant - Provider who is requesting to become a contracted provider of the
Gateway Community Health. (Operational P&P)
Provider Applicant Appeal Process - The internal process of reviewing the provider
application information that originally was denied upon recommendation by the Network
Management Workgroup. (Operational P&P)
Provider Application Process - Process a potential provider must follow when
requesting to become a contracted provider for the Gateway Community Health.
(Operational P&P)
Provider Dispute - A written communication by a provider, primarily indicating
disagreement or expressing dissatisfaction with an administrative decision (Operations)
Provider Network -The network of providers contracted by MCPN and all Contracted
Providers to deliver Covered Services to Recipients. (DWCCMHA/MCPN Contract)
Provider Service & Network Management Departments -The departments at Gateway
that are responsible for recommending, processing, and executing provider contracting
and Provider Service requirements.
101
Provider Sponsored Specialty Networks (PSSN) - Vertically integrated, comprehensive
service entities that are organized and operated by affiliated groups of service
providers that offer relatively complete "systems of care" for beneficiaries with
particular service needs. DWCCMHA uses the term MCPN as an alternative to PSSN.
(DWCCMHA/MCPN Contract)
Psychiatric Partial Hospitalization Program - A nonresidential treatment program that
provides psychiatric, psychological, social, occupational, nursing, music therapy, and
therapeutic recreational services under the supervision of a physician to adults
diagnosed as having serious mental illness or minors diagnosed as having serious
emotional disturbance who do not require 24-hour continuous mental health care, and
that is affiliated with a psychiatric hospital or psychiatric unit to which consumers may be
transferred if they need inpatient psychiatric care. (DWCCMHA/MCPN Contract)
QMRP -A Qualified Mental Retardation Professional is a person with specialized training or
experience in treating or working with persons with mental retardation and is one of the
following:
1. Educator with a degree in education from an accredited program.
2. Occupational therapist:
a. A graduate of an occupational therapy curriculum accredited jointly by the Council
on Medical Education of the American Medical Association and the American
Occupational Therapy Association; or
b. Is eligible for certification by the American Occupational Therapy
Association under its requirements; or
c. Has two years of appropriate experience as an occupational therapist and
has achieved a satisfactory grade on an approved proficiency examination,
except that such determination of proficiency does not apply to persons
initially licensed by the State or seeking initial qualifications as an
occupational therapist after December 31, 1977.
3. Physical therapist:
a. Licensed as a physical therapist by the State
b. has graduated from a physical therapy curriculum approved by the American
Physical Therapy Association or by the Council on Medical Education and
Hospitals of the American Medical Association
c. Has two years of appropriate experience as a physical therapist, after
December 31, 1977.
4. Physician of medicine or osteopathy, licensed by the State.
5. Psychologist with a master's degree from an accredited program.
6. Registered nurse: currently licensed by the State of Michigan
7. Social worker with a bachelor's degree in:
a. social work from an accredited program; or
b. in a field other than social work and at least three years of social work
experience under the supervision of a qualified social worker.
c.
102
8. Speech pathologist or audiologist (qualified consultant):
a. Licensed by the State and is eligible for a certificate of clinical competence
in speech pathology or audiology granted by the American Speech and
Hearing Association; or
b. Meets the educational requirements for certification, and is in the process
of accumulating the supervised experience required for certification.
9. Therapeutic recreation specialist:
a. Graduate of an accredited program; and
b. Licensed or registered by the State.
10. Rehabilitation counselor: certified by the Committee on Rehabilitation Counselor for
Certification. (DWCCMHA/MCPN Contract)
QPIC - Quality Performance and Improvement Council (DWCCMHA/MCPN Contract)
Qualified Health Plan (QHP) - A health plan (e.g., HMO, PPO, POS) in which a Medicaid
recipient may belong. The QHP pays for mental health services when a consumer is
Medicaid eligible, but does not meet the DD, SMI or SED requirements.
(DWCCMHA/MCPN Contract)
Qualified Mental Health Professional - A qualified mental health professional is licensed,
certified or registered by the State of Michigan or a national organization to provide
mental health services and clinical and administrative supervision. (DWCCMHA/MCPN
Contract)
Reasonable Access - (geographic access standard) Services are available within 30
miles or 30 minutes in urban areas or within 60 miles or 60 minutes in rural areas
(DWCCMHA/MCPN Contract)
Recovery - The over arching message of recovery is that hope and restoration of a
meaningful life are possible, despite serious mental illness. Instead of focusing primarily on
symptom relief, as the medical model dictates, recovery casts a much wider spotlight on
restoration of self-esteem and identity and on attaining meaningful roles in society.
(DWCCMHA/MCPN Contract)
Respite - Respite services are those services that are provided in the individual's/family's
home or outside the home to temporarily relieve the unpaid primary caregiver. Respite
services provide short-term care to a child with a mental illness/emotional disturbance to
provide a brief period of rest or relief for the family from day to day care giving for a
dependent family member. Respite programs can use a variety of methods to achieve the
outcome of relief from care giving including family friends, trained respite workers, foster
homes, residential treatment facilities, respite centers, camps and recreational facilities.
Respite services are not intended to substitute for the services of paid support/training
staff, crisis stabilization and crisis residential treatment or out-of-home placement.
(DWCCMHA/MCPN Contract)
103
Root Cause Action Plan - The ―Root Cause Action Plan‖ is the product of the Root
Cause Analysis that identifies the strategies for implementation to reduce the
probability of Sentinel Events occurring in the future. The Action Plan addresses
responsibility for implementation, oversight, pilot testing as appropriate, timelines,
and strategies for achieving improvements to reduce risk, including measurement of the
effectiveness of the actions. (DWCCMHA/MCPN Contract)
Root Cause Analysis - A structured and process-focused framework for identifying and
evaluating the basis or causal factors involved in producing a sentinel event. The analysis
should include the development of an action plan that identifies the steps that will be
implemented to lessen the risk that similar events would happen to have happen.
(DWCCMHA/MCPN Contract)
Root Cause Analysis Administrative/Managed Care Component - The non peerreviewed portion (generally, but not limited to, the non-clinical portion) of the Root Cause
Analysis shall be conducted by Gateway ‗s MQC Department upon referral by the Incident
Review Committee (IRC), and by the legal entity or entities contracted with or
subcontracted under Gateway Community Health to provide community mental health
services/supports to affected Recipients.
Screening - Means the CMH has been notified of the Person and has been provided
enough information to make a determination of the most appropriate services. The
screening may be provided on-site, face-to-face, by CMH personnel, or, over the
telephone. (DWCCMHA/MCPN Contract)
Second Opinion/Reconsideration - An additional clinical evaluation and decision
provided in response to a request from an applicant, authorized representative or referring
mental health professional, in dispute of an adverse decision when: 1) A specific
request for inpatient hospitalization has been denied by a psychiatrist reviewer, and 2)
Following a face-to-face assessment by a qualified professional, determination is made
that no mental health service is needed and the applicant is referred outside DWCCMHA
network to other human service resources. (DWCCMHA/MCPN Contract)
Secondary Treatment - Secondary treatment services are those which are provided by
professionals other than the treating clinician (for instance, a psychiatrist who performs a
consultation or a social worker who conducts a daily living skills group at a partial
hospitalization program), and individuals from relevant medical delivery systems, including
Primary Care Physicians (PCPs). (Operational P&P)
Sentinel Event - Unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or
function. The phrase "or the risk thereof" includes any process variation for which a
recurrence would carry a significant chance of a serious adverse outcome.
(DWCCMHA/MCPN Contract)
104
Serious Emotional Disturbance - A diagnosable mental, behavioral, or emotional
disorder affecting a minor that exists or has existed during the past year for a period of
time sufficient to meet diagnostic criteria specified in the most recent diagnostic and
statistical manual of mental disorders published by the American Psychiatric
Association and approved by the MDCH, and that has resulted in functional
impairment that substantially interferes with or limits the minor's role or functioning in
family, school or community services. The following disorders are included only if they
occur in conjunction with another diagnosable serious emotional disturbance: 1. A
substance use disorder; 2. A developmental disorder; 3. A "V" code in the diagnostic and
statistical manual of mental disorders. (DWCCMHA/MCPN Contract)
Serious Mental Illness - Diagnosable mental, behavioral, or emotional disorder
affecting an adult that exists or has existed within the past year for a period of time
sufficient to meet diagnostic criteria specified in the most recent diagnostic and statistical
manual of mental disorders, published by the American Psychiatric Association and
approved by the MDCH, in functional impairment that substantially interferes with or
limits one or more major life activities. Serious mental illness includes dementia with
delusions, dementia with depressed mood and dementia occurs in conjunction with
another diagnosable serious mental illness. The following disorders are included only if
they occur in conjunction with another diagnosable mental illness: 1) A substance
abuse disorder 2) A developmental disorder 3) A "V" code in the diagnostic and
statistical manual of mental disorders. (DWCCMHA/MCPN Contract)
Service Authorization - A process designed to help assure that planned services meet
medical necessity criteria, and are appropriate to the conditions, needs and desires of the
individual. Authorization can occur before services are delivered, at some point during
service delivery or can occur after services have been delivered based on a retrospective
review. (DWCCMHA/MCPN Contract)
Stakeholder - An individual or entity that has an interest, investment or involvement in the
operations of a Prepaid Inpatient Health Plan or affiliate. Stakeholders can include
individuals and their families, advocacy organizations, and other members of the
community that are affected by the Prepaid Inpatient Health Plan and the supports and
services it offers. (DWCCMHA/MCPN Contract)
State Hospital Services - An inpatient program operated by the Michigan Department of
Community Health for the treatment of individuals with serious mental illness or serious
emotional disturbance. (DWCCMHA/MCPN Contract)
Sub-capitation -A fixed amount paid per month per enrolled consumer, which shares risk
with affiliates or established risk-sharing entities. (DWCCMHA/MCPN Contract)
105
Substance Abuse - A maladaptive pattern of substance use manifested by recurrent and
significant adverse consequences related to the repeated use of substances. If the primary
diagnosis is mental illness, then the CMH will be the lead agency for the determination of
necessary services, with coordination with the Substance Abuse Coordinating Agency.
If the primary diagnosis is substance abuse, then the Substance Abuse Coordinating
Agency will be the lead agency for the determination of necessary services, with
coordination with the CMH. (DWCCMHA/MCPN Contract)
Substance Use Disorders - Substance use disorders include Substance
Dependence and Substance Abuse, according to selected specific diagnosis criteria
given in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Specific DSM IV diagnoses are found in Attachment 7.0.1.1 of the department's
contract with CMHSPs. Technical Advisory MDCH – developed document with
recommended parameters (DWCCMHA/MCPN Contract)
Technical Requirement - MDCH/PIHP contractual requirements providing parameters
for PIHPs regarding administrative practice related to specific administrative functions,
and derived from public policy and legal requirements. (DWCCMHA/MCPN Contract)
TPL Third Party Liability – refers to any other health insurance plan or carrier (e.g.,
individual, group, employer-related, self-insured or self-funded plan or commercial carrier,
automobile insurance and worker's compensation) or program (e.g., Medicare) that
has liability for all or part of a recipient's covered benefit. (DWCCMHA/MCPN
Contract)
UM Designee - Person or entity designated by DWCCMHA to oversee the UM Plan.
(DWCCMHA/MCPN Contract)
UM Plan - A utilization management plan for the Provider Network, which includes
comprehensive, written utilization management policies and procedures that evaluate
the appropriateness and effectiveness of Covered Services provided by the MCPN and
the Contracted Providers, and is approved by DWCCMHA. (DWCCMHA/MCPN
Contract)
Utilization Management (UM) - The process of evaluating the necessity,
appropriateness and efficiency of health care services against established guidelines and
criteria and the evaluation of the necessity, appropriateness, and efficiency of the use
of health care services, procedures, and facilities. (Operations). Using established
criteria to recommend or evaluate services provided in terms of medical necessity,
effective use of resources and cost-effectiveness. (DWCCMHA/MCPN Contract)
Utilization Review (UR) - Analysis of the patterns of service authorization decisions and
service usage in order to determine the means for increasing value of services provided
(minimize cost and maximize effectiveness/ appropriateness).
106
Urgent Situation - A situation in which an individual is determined to be at risk of
experiencing an emergency situation in the near future if he or she does not receive care,
treatment, or support services. (DWCCMHA/MCPN Contract)
Wraparound Services - Wraparound services are an individually designed set of services
provided to minors with serious emotional disturbance or serious mental illness and their
families that includes treatment services and personal support services or any other
supports necessary to maintain the child in the family home. Wraparound services are
to be developed through an interagency collaborative approach and a minor's parent
or guardian and a minor age 14 or older are to collaborate in planning the services.
(DWCCMHA/MCPN Contract)
Your Choice - The term originally designated by DWCCMHA for its program for the
delivery of pre-paid behavioral health services through its MCPN contracts.
(DWCCMHA/MCPN Contract)
107
Section XIII
Addendums
PIHP/CMHSP Encounter Reporting HCPCS and Revenue Codes -Link
http://www.michigan.gov/documents/mdch/MHCodeChart10-01-07 210734 7.doc
Medicaid Application – Linkhttp://www.michigan.gov/dhs/0,1607,7-124-5453 5530--,00.html
Medicaid Provider Manual – Link http://www.mdch.state.mi.us/dchmedicaid/manuals/MedicaidProviderManual.pdf
Michigan Department of Community Health Approved Diagnosis Codes – Link
http://www.michigan.gov/documents/mdch/MHCodeChart_7-01-09_285851_7.doc
Person Centered Planning Best Practice Guideline
Attachment 4.5.1.1 to the contract between CMH and DCH
I. Summary/Background
The Michigan Mental Health Code establishes the right for all individuals to have their
Individual Plan of Service developed through a person-centered planning process
regardless of age, disability or residential setting. The Individual Plan of Service may
include a treatment plan, support plan or both. In the past, Medicaid or other
regulatory standards have governed the process of treatment or support plan
development. These standards drove the planning process through requirements on the
types of assessments to be completed and the professionals to be involved. Personcentered planning departs from this approach in that the individual will direct the
planning process with a focus on what he/she wants and needs. Professionally trained
staff will play a role in the planning and delivery of treatment and may play a role in the
planning and delivery of supports. However, the development of the treatment or
support plan, including the identification of possible services and professionals, is based
upon the expressed needs and desires of the individual.
The Michigan Department of Community Health (MDCH) has advocated and
supported a family approach to service delivery for children and their families. This
approach recognizes the importance of the family system and the fact that supports
and services will impact the entire system. Therefore, in the case of minors, the
child/family will be the focus of service planning and family members are integral to the
planning process and its success. The wants and needs of the child/family will be
considered in the planning and evaluation of supports, services and/or treatment.
108
Managed care strategies will play an important role in planning for and delivery of
supports, services and/or treatment. Person-centered planning fits well with these
strategies.
Both strategies attempt to ensure that individuals are provided with the most
appropriate services necessary to achieve the desired outcomes. When an individual
expresses a choice or preference for a support, service and/or treatment for which an
appropriate alternative of lesser cost exists, a process for dispute resolution and
appeal may be indicated. This document provides guidelines for addressing dispute
concerns.
The literature describes specific methods for person-centered planning, including but
not limited to, individual service design, Personal Futures Planning, McGill Action
Planning Systems, Essential Lifestyle Planning, Planning Alternative Tomorrows With
Hope, etc. This practice guideline does not support one model over another. It does,
however, define the values, principals and essential elements of the person-centered
planning process and it provides illustrations to its application.
II. Values and Principles Underlying Person-Centered Planning
Person-centered planning is a highly individualized process designed to respond to the
expressed needs/desires of the individual.
A. Each individual has strengths, and the ability to express preferences and to make
choices.
B. The individual's choices and preferences shall always be considered if not always
granted.
C. Professionally trained staff will play a role in the planning and delivery of
treatment and may play a role in the planning and delivery of supports. Their
involvement occurs if the individual has expressed or demonstrated a need that
could be met by professional intervention.
D. Treatment and supports identified through the process shall be provided in
environments that promote maximum independence, community connections and
quality of life.
E. A person's cultural background shall be recognized and valued in the decisionmaking process.
III. Practice Guidelines
A. Essential Elements
1. The individual shall be given ongoing opportunities to express his/her needs or
desired outcomes. This would include:
a. Making accommodations for communication to maximize ability for
expression;
109
b. The identification of outcomes of value for the individual; and
c. Expectations of the service delivery system.
2. Potential support and/or treatment options to meet the expressed needs of the
individual are identified and discussed with the individual.
3. The individual shall be given ongoing opportunities to express his/her
preferences and to make choices. This would include:
a. Choices and options shall be clearly explained.
b. To the extent possible, the individual shall be given the opportunity for
experiencing the options available prior to making a choice/decision. This is
particularly critical for those persons who have limited life experiences in
the community with respect to housing, work and other domains.
c. Individuals who have court-appointed legal guardians shall
participate in person-centered planning to the maximum extent possible
and shall have authority not otherwise specifically delegated to the
guardian.
d. Parents and significant family members of minors are integral to and shall
participate in the planning process unless:
i. The minor is fourteen years of age or older and has requested
services without the knowledge or consent of parents, guardian or
person in loco parentis within the restrictions stated in the Mental
Health Code;
ii. The minor is emancipated; or
iii. The inclusion of the parent(s) or significant family members would
constitute a substantial risk of physical or emotional harm to the
recipient or substantial disruption of the planning process as stated
in the Mental Health Code. Justification of the exclusion of
parents shall be documented in the clinical record.
4. Individuals are provided with opportunities to provide feedback on how they
feel about the service, support and/or treatment they are receiving and
their progress toward attaining valued outcomes.
B. Illustrations of Individual Needs
Person-centered planning processes begin when the individual makes a request to the
Responsible Mental Health Agency (RMHA). The first step is to find out from the individual
the reason for his/her request for assistance. During this process, individual needs and
valued outcomes are identified rather than requests for a specific type of service. Since
person-centered planning is an individualized process, how the RMHA proceeds will
depend upon what the individual requests.
This guideline includes a chart of elements/strategies that can be used by the person
representing the RMHA depending upon what the individual wants and needs. Three
possible situations are:
110
1.
The individual expresses a need which would be considered urgent or
emergent. When an individual is in an urgent/emergent situation, the goal is
to get the individual's crisis situation stabilized. Following stabilization, the
individual and RMHA will explore further needs for assistance and if required,
proceed to a more in-depth planning process as outlined below. It is in this
type of situation where an individual's opportunity to make choices may be
limited.
2. The individual expresses a need or makes a request for a support,
service and/or treatment in a single life domain and/or of a short duration.
A life domain could be any of the following:
a. Daily activities;
b. Social relationships;
c. Finances;
d. Work;
e. School;
f. Legal and safety;
g. Health;
h. Family relationships; etc.
3.
The individual expresses multiple needs which involve multiple life domains
for support(s), service(s) or treatment of an extended duration.
The following chart represents the elements/strategies that can be used depending
on the kinds of needs expressed by the individual.
IV. Assurances and Indicators of Person-Centered Planning Implementation
It is the responsibility of the RMHA to assure that the Individual Plan of Service is
developed utilizing a person-centered planning process. Below are examples of
systemic and individual level indicators which would demonstrate that personcentered planning has occurred. The methods of gathering information or evidence
may vary and include the review of administrative documents, clinical policy and
guidelines, case record review and interviews/focus groups with individuals and their
families.
A. Systemic indicators would include, but not be limited to:
1. The RMHA has a policy or practice guideline which delineates how personcentered planning will be implemented;
2. Evidence that the RMHA informs individuals of their right to person- centered
planning and associated appeal mechanisms, investigates complaints in this
area, and documents outcomes;
3. Evidence that the RMHA's quality improvement system actively seeks feedback
from individuals receiving services, support and/or treatment regarding their
satisfaction providing opportunities to express needs and preferences and the
ability to make choices; and
111
4. The RMHA's staff development plan includes efforts to ensure that staff involved
in managing, planning and delivering support and/or treatment services are
trained in the philosophy and methods of person-centered planning.
B. Individual indicators could include but not be limited to:
1. Evidence the individual was provided with information of his/her right to personcentered planning;
2. Evidence that the individual chose whether or not other persons should be
involved and those identified were involved in the planning process and in the
implementation of the Individual Plan of Service;
3. Evidence that the individual chose the places and times to meet,
convenient to the individual and to the people he/she wanted present;
4. Evidence that the individual had choice in the selection of treatment or
support services and staff;
5. Evidence that the individual's preferences and choices were
considered, or a description of the dispute/appeal process and the resulting
outcome; and
6. Evidence that the progress made toward the valued outcomes identified
by the individual was reviewed and discussed for the purpose of modifying
the strategies and techniques employed to achieve these outcomes.
V. Dispute Resolution/Appeal Mechanisms
1. If in the judgment of the person representing the RMHA, an individual
requests inpatient treatment, or a specific mental health support or service for
which appropriate alternatives for the individual exist that are of equal or greater
effectiveness and equal or lower cost, to the RMHA should:
a. Identify and discuss the underlying reasons for the
request/preference; b. Identify and discuss alternatives with the
individual; and c. Negotiate toward a mutually acceptable support,
service and/or treatment.
In the event that a mutually acceptable alternative cannot be reached, the
person representing the RMHA should:
112
a. Document the individual's preference, the support, service and/or
treatment the RMHA is offering, and the reason for not accepting that
preference; b. Inform the individual of their right to appeal the decision as
permitted in the Grievance and Appeal Technical Requirement attachment
to the MDCH/CMHSP Managed Specialty Supports and Services
Contract. This would include:
i. His/her right to contact the recipient rights office for
consultation, mediation or intervention in response to their
request for a specific mental health support or service; ii.
His/her right to request a second opinion as referenced in the
Mental Health Code, if requesting inpatient treatment; and iii.
His/her right to a Fair Hearing, if a recipient of Medicaid coverage.
2. If in the judgment of the RMHA, an individual's choice or preference for the
inclusion or exclusion of a planning participant, meeting location or specific
provider poses an issue of health or safety or exceeds reasonable
expectations of resource consumption, the RMHA should discuss and identify the
individual's underlying reason for that specific choice or preference and negotiate
toward a mutually acceptable alternative that meets the outcomes intended.
3. If an individual is not satisfied with his/her Individual Plan of Service, the
Michigan Mental Health Code allows the individual to make a request for
review to the designated individual in charge of implementing the plan. The
review shall be completed within 30 days and shall be carried out in a manner
approved by the appropriate governing body. In addition, the individual has
access to the appeal processes as defined in the Grievance and Appeal
Technical Requirement of the MDCH/CMHSP Managed Specialty Supports and
Services Contract.
4. If the individual believes that the opportunity for person-centered planning is
not provided as specified in the manner above, it is the responsibility of the
RMHA to inform the individual of his/her right to consult with the recipient
rights office.
5. When there is a disagreement between an individual and the legal guardian or
responsible parent, the RMHA staff should attempt to mediate between the two
parties in order to provide an outcome which is acceptable to both parties.
VI. Definitions
Case Manager/Supports Coordinator: The staff person who works with the individual
to gain access to and coordinate the services, supports and/or treatment which the
individual wants or needs.
113
Emancipated Minor: The termination of the rights of the parents to the custody, control,
services and earnings of a minor which occurs by operation of law or pursuant to a
petition filed by a minor with the probate court.
Emergency Situation: A situation when the individual can reasonably be expected in
the near future to physically injure himself, herself, or another person; is unable to
attend to food, clothing, shelter or basic physical activities that may lead to future harm
or the individual's judgment is impaired leading to the inability to understand the need for
treatment resulting in physical harm to self or others.
Family Member: A parent, stepparent, spouse, sibling, child, or grandparent of a
primary consumer, or an individual upon whom a primary consumer is dependent for at
least 50 percent of his or her financial support.
Guardian: A person appointed by the court to exercise specific powers over an individual
who is a minor, legally incapacitated or developmentally disabled.
Individual Plan of Service: A written Individualized Plan of Service directed by the
individual as required by the Mental Health Code. This may be referred to as a treatment
plan or a support plan.
Minor: An individual under the age of 18 years.
Person-Centered Planning: A process for planning and supporting the individual
receiving services that build upon the individual's capacity to engage in activities that
promote community life and honor the individual's preferences, choices, and abilities. The
person-centered planning process involves families, friends, and professionals as the
individual desires or requires.
Responsible Mental Health Agency (RMHA): A Community Mental Health Services
Program responsible for arranging and/or coordinating the provision of services for the
individual.
Urgent Situation: A situation in which an individual is determined to be at risk of
experiencing an emergency situation in the near future if he or she does not receive
care, treatment or support services.
VII. Legal References:
Mental Health Code Act, 258 MI. §§ 409-1-7 (1974 & Supp. 1996). Mental Health Code
Act, 258 MI. §§ 700-g (1974 & Supp. 1996). Mental Health Code Act, 258 MI. §§ 707-1-5
(1974 & Supp. 1996). Mental Health Code Act, 258 MI. §§ 712-1-3 (1974 & Supp. 1996).
114
Consumerism Best Practice Guideline
I. Summary
This guideline sets policy and standards for consumer inclusion in the service
delivery design and delivery process for all public mental health services.
This guideline ensures the goals of a consumer-driven system which gives consumers
choices and decision-making roles. It is based on the active participation of primary
consumers, family members and advocates in gathering consumer responses to
meet these goals.
This participation by consumers, family members and advocates is the basis of a
provider‘s evaluation. Evaluation also includes how this information guides
improvements.
II. Application
A. Psychiatric hospitals operated by the Michigan Department of Community Health
(MDCH).
B. Centers for persons with developmental disabilities and community agencies operated
by the MDCH.
C. Children‘s psychiatric hospitals operated by the MDCH.
D. Special facilities operated by the MDCH.
E. Community Mental Health Services Programs (CMHSPs) under contract with MDCH.
F. All providers of mental health services who receive public funds, either directly or by
contract, grant, third party payers, including managed care organizations or other
reimbursements.
III. Policy
This policy supports services that advocate for and promote the needs, interests, and
well-being of primary consumers. It is essential that consumers become partners in
creating and evaluating these programs and services. Involvement in treatment
planning is also essential.
Services need to be consumer-driven and may also be consumer-run. This policy
supports the broadest range of options and choices for consumers in services. It also
supports consumer-run programs which empower consumers in decision-making of
their own services.
115
All consumers need opportunities and choices to reach their fullest potential and live
independently. They also have the rights to be included and involved in all aspects of
society.
Accommodations shall be made available and tailored to the needs of consumers as
specified by consumers for their full and active participation as required by this
guideline.
IV. Definitions
Informed Choice: means that an individual receives information and understands his or
her options.
Primary Consumer: means an individual who receives services from the Michigan
Department of Community Health or a Community Mental Health Services Program. It
also means a person who has received the equivalent mental health services from the
private sector.
Consumerism: means active promotion of the interests, service needs, and rights of
mental health consumers.
Consumer-Driven: means any program or service focused and directed by participation
from consumers.
Consumer-Run: refers to any program or service operated and controlled exclusively by
consumers.
Family Member: means a parent, stepparent, spouse, sibling, child, or grandparent of a
primary consumer. It is also any individual upon whom a primary consumer depends for
50 percent or more of his or her financial support.
Minor: means an individual under the age of 18 years.
Family Centered Services: means services for families with minors who emphasize
family needs and desires with goals and outcomes defined. Services are based on
families‘ strengths and competencies with active participation in decision-making
roles.
Person-Centered Planning: means the process for planning and supporting the
individual receiving services. It builds upon the individual‘s capacity to engage in
activities that promote community life. It honors the individual‘s preferences, choices,
and abilities.
Person-First Language: refers to a person first before any description of disability.
116
Recovery: means the process of personal change in developing a life of purpose, hope,
and contribution. The emphasis is on abilities and potentials. Recovery includes
positive expectations for all consumers. Learning self-responsibility is a major element
to recovery.
V. Standards
A. All services shall be designed to include ways to accomplish each of these standards:
1. ―Person-First Language‖ shall be utilized in all publications, formal communications,
and daily discussions.
2. Provide informed choice through information about available options.
3. Respond to an individual‘s ethnic and cultural diversities. This includes the
availability of staff and services that reflect the ethnic and cultural makeup of the
service area. Interpreters needed in communicating with non-English and limited
English-speaking persons shall be provided.
4. Promote the efforts and achievements of consumers through special recognition of
consumers.
5. Through customer satisfaction surveys and other appropriate consumer related
methods, gather ideas and responses from consumers concerning their experiences
with services.
6. Involve consumers and family members in evaluating the quality and effectiveness
of service. Administrative mechanisms used to establish service must also be
evaluated. The evaluation is based upon what is important to consumers, as
reported in customer satisfaction surveys.
7. Advance the employment of consumers within the mental health system and in the
community at all levels of positions, including mental health service provision roles.
B. Services, programs, and contracts concerning persons with mental illness and
related disorders shall actively strive to accomplish these goals:
1. Provide information to reduce the stigma of mental illness that exists within
communities, service agencies, and among consumers.
2. Create environments for all consumers in which the process of "recovery" can occur.
This is shown by an expressed awareness of recovery by consumers and staff.
3. Provide basic information about mental illness, recovery, and wellness to
consumers and the public.
C. Services, programs, and contracts concerning persons with developmental disabilities
shall be based upon these elements:
1. Provide personal preferences and meaningful choices with consumers in control over
the choice of services and supports.
117
2. Through educational strategies: promote inclusion, both personal and in the
community; strive to relieve disabling circumstances; actively work to prevent
occurrence of increased disability; and promote individuals in exercising their abilities
to their highest potentials.
3. Provide roles for consumers to make decisions in policies, programs, and services
that affect their lives including person-centered planning processes.
D. Services, programs, and contracts concerning minors and their families shall be based
upon these elements:
1. Services shall be delivered in a family-centered approach, implementing comprehensive
services that address the needs of the minor and his/her family.
2. Services shall be individualized and respectful of the minor and family‘s choice of
services and supports.
3. Roles for families to make decisions in policies, programs and services that affect
their lives and their minor‘s life.
E. Consumer-run programs shall receive the same consideration as all other providers of
mental health services. This includes these considerations:
1.
2.
3.
4.
5.
Clear contract performance standards.
Fiscal resources to meet performance expectations.
A contract liaison person to address the concerns of either party.
Inclusion in provider coordination meetings and planning processes.
Access to information and supports to ensure sound business decisions.
F. Current and former consumers, family members, and advocates must be invited to
participate in implementing this guideline. Provider organizations must develop
collaborative approaches for ensuring continued participation.
Organizations‘ compliance with this guideline shall be locally evaluated. Foremost, this
must involve consumers, family members, and advocates. Providers, professionals, and
administrators must be also included. The CMHSP [Community Mental Health Service
Provider] shall provide technical assistance. Evaluation methods shall provide
constructive feedback about improving the use of this guideline. This guideline requires
that it be part of the organizations‘ Continuous Quality Improvement.
VI. References and Legal Authority
Act 258, Section 116(e), Public Acts of 1974 as amended, being MCL 330.1116, 1704,
1708.
118
Self-Determination Policy & Practice Guideline
Michigan Department of Community Health
Mental Health and Substance Abuse Services
July 18, 2003
Introduction
Self-determination incorporates a set of concepts and values that emphasize
participation and the achievement of personal control for individuals served through the
public mental health system. These concepts and values stem from a core belief that
people who require support through the public mental health system must have freedom
not only to define the life they seek, but to be supported to direct the assistance they
require in pursuit of that life. Persons who rely on the public mental health system for
necessary supports and services must have access to meaningful options from which to
make choices, and be supported to control the course of their lives.
Arrangements that support self-determination must be sponsored by the public mental
health system, assuring methods for the person to exert direct control over how, by
whom, and to what ends they are served and supported.
Person-centered planning (PCP) is a central element of self-determination. PCP is the
crucial medium for expressing and transmitting personal needs, wishes, goals and
aspirations. As the PCP process unfolds, the appropriate mix of paid/non-paid services
and supports to assist the individual in realizing/achieving these personally- defined goals
and aspirations are identified. The principles of self-determination recognize the rights
of people supported by the mental health system to have a life with freedom, and to
access and direct needed supports that assist in the pursuit of their life, with responsible
citizenship.
The methods applicable to self-determination provide a route for the person to
engage in activities that accompany a meaningful life. Activities that promote deep
community connections, the opportunity for real work, ways to contribute to one‘s
community, and participation in personally-valued experiences must be among the
purposes of supports the person may need. These supports function best when they
build upon natural community experiences and opportunities. The person determines and
manages needed supports in close association with chosen friends, family, neighbors,
and co-workers as a part of an ordinary community life.
Person-centered planning and self-determination underscore a commitment in
Michigan to move away from traditional service approaches for consumers of the
public mental health system.
119
In Michigan, the flexibility provided through the Medicaid 1915(b) Specialty Services
waiver, together with the Mental Health Code requirements of PCP have reoriented
organizations to respond in new and more meaningful ways. Recognition has increased
among providers and professionals that many consumers may not need, want, or benefit
from a clinical regimen, especially when imposed without clear choice.
Many provider agencies are learning ways to better support the consumer to choose,
participate in, and accomplish a life with personal meaning. This has meant, for example,
reconstitution of segregated programs into non-segregated intervention options that
connect better with community life.
However, the move away from predefined programmatic approaches and
professionally managed models has many barriers. Conflicts of interest abound
among many who manage the current system. Agencies and providers have
obligations and underlying values that affirm the principles of choice and control. Yet,
they also have long-standing investments in existing programs and services,
including their investments in capital and personnel resources. Even when options are
expanded, the choices currently available seldom dissolve the isolation of people with
disabilities, reduce the segregation, nor necessarily promote participation in community
life and the realization of full citizenship rights.
The Department of Community Health is supportive of the desire of people who use the
services of the public mental health system to have a full and meaningful role in
controlling and directing their specialty mental health services and supports
arrangements. At the same time, the Department knows that the system change
requirements, as outlined in this policy and practice guideline, are not simple in their
application. The Department is committed to continuing dialogue with stakeholders
and to the provision of support, direction and technical assistance so the system may
make successful progress to resolve technical difficulties and apparent barriers, to
achieve real, measurable progress in the implementation of this policy. This policy is
intended to clarify the essential aspects of arrangements that promote opportunity for
self-determination, and define required elements of these arrangements.
Purpose
I. To provide policy direction that defines and guides the practice of selfdetermination within the public mental health system in order to assure that
arrangements which support self-determination are made available as a means for
achieving consumer-designed plans of specialty mental health services and supports.
Core Elements
I. Consumers are to be provided with information about the principles of selfdetermination and the possibilities, models and arrangements involved. Consumers
shall have access to the tools and mechanisms supportive of self-determination,
upon request.
120
II. Self-determination arrangements shall commence when the CMHSP and the
consumer reach an agreement on a plan of specialty mental health services and
supports, the amount of mental health and other public resources to be authorized
to accomplish the plan, and the arrangements through which authorized public mental
health resources will be controlled, managed, and accounted for.
III. Within the obligations that accompany the use of funds provided to them,
CMHSPs shall ensure that their services planning and delivery processes are
designed to encourage and support consumers to decide and control their own lives.
The CMHSP shall offer and support easily-accessed methods for consumers to
control and direct an individual budget. This includes providing them with methods
to authorize and direct the delivery of specialty mental health services and supports
from qualified providers selected by the consumer.
III. Consumers of services of the public mental health system shall direct the use of
resources in order to choose meaningful specialty mental health services and
supports in accordance with their plan as developed through a person-centered
planning process.
IV. Fiscal responsibility and the wise use of public funds shall guide the consumer
and the CMHSP in reaching an agreement on the allotment and use of funds
comprising an individual budget.
V. Accountability for the use of public funds must be a shared responsibility of the
CMHSP and the consumer, consistent with the fiduciary obligations of the CMHSP.
VI. Realization of self-determination principles requires arrangements that are
partnerships between the CMHSP and the consumer. They require the active
commitment of the CMHSP to provide a range of options for consumer choice and
control of personalized Provider Servicehips within an overall environment of
person-centered supports.
VII. In the context of this partnership, CMHSPs must actively assist consumers with
prudently selecting qualified providers and otherwise support the consumer with
successfully using resources allotted in an individual budget.
VIII. Issues of health, safety and well-being are central to assuring successful
accomplishment of a consumer‘s plan of specialty mental health services and
supports. These issues must be addressed and resolved using the person-centered
planning process, balancing consumer preferences and opportunities for self direction with CMHSP obligations under federal and state law and applicable
Medicaid Waiver regulations. Resolutions should be guided by the consumer‘s
preferences and needs, implemented in ways that maintain the greatest opportunity
for consumer control and direction.
121
IX. Self-determination requires recognition that there may be strong inherent
conflicts of interest between the consumer‘s choices and current methods of
planning, managing and delivering specialty mental health services and supports.
X. The CMHSP must watch for and seek to minimize or eliminate either potential or
actual conflicts of interest between itself and its provider systems, and the processes and
outcomes sought by the consumer.
IX. Arrangements that support self-determination, allowing a consumer to choose,
control and direct providers of specialty mental health services and supports are not
themselves covered services under the Specialty Mental Health Plan. They are
administrative mechanisms. Self-determination arrangements must be developed and
operated within the requirements of the Prepaid Health Plan contract between the
CMHSP and the State of Michigan and in accordance with federal and state law.
Involvement in self-determination does not change a consumer‘s eligibility for
particular specialty mental health services and supports.
Policy
III. Opportunity to pursue and obtain a plan incorporating arrangements that support
self-determination shall be established in each Community Mental Health Services
Program, for adults with developmental disabilities and adults with mental illness. Each
CMHSP shall develop and make available a set of methods that provide opportunities
for the consumer to control and direct their specialty mental health services and
supports arrangements.
IV.
A. Participation in self-determination shall be a voluntary option on the part of the
consumer.
B. Consumers involved in self-determination shall have the authority to select, control
and direct their own specialty mental health services and supports arrangements by
responsibly controlling the resources allotted in an individual budget, towards
accomplishing the goals and objectives in their plan of specialty mental health
services and supports.
C. A CMHSP shall assure that full and complete information about self-determination and
the manner in which it may be accessed and applied is provided to each consumer.
This shall include specific examples of alternative ways that a consumer may use to
control and direct an individual budget, and the obligations associated with doing this
properly and successfully.
D. Self-determination shall not serve as a method for a CMHSP to reduce its
obligations to the consumer, or to avoid the provision of needed specialty mental health
services and supports.
122
E. A CMHSP shall actively support and facilitate a consumer‘s application of the principles
of self-determination in the accomplishment of his/her plan of services.
II. Arrangements that support self-determination shall be made available to each
consumer for whom an agreement on a plan of authorized specialty mental health
services and supports, along with an acceptable individual budget, has been
reached. A consumer initiates this process by requesting the opportunity to
participate in self-determination. For the purposes of self-determination, reaching
agreement on the plan must include delineation of the arrangements that will, or may, be
applied by the consumer to select, control and direct the provision of those services
and supports.
A. Development of an individual budget shall be done in conjunction with
development of a plan of specialty mental health services and supports, using a personcentered planning process.
B. As part of the planning process leading to an agreement about self-determination, the
arrangements that will, or may, be applied by the consumer to pursue selfdetermination shall be delineated and agreed to by the consumer and the CMHSP.
C. The individual budget represents the expected or estimated costs of a concrete approach
to accomplishing the consumer‘s plan.
D. The amount of the individual budget shall be formally agreed to by both the
consumer and the CMHSP before it may be authorized for use by the consumer. A copy
of the individual budget must be provided to the consumer prior to the onset of a selfdetermination arrangement.
E. Proper use of an individual budget is of mutual concern to the CMHSP and the
consumer.
1. Mental Health funds included in an individual budget are the assets and
responsibility of the CMHSP, and must be used consistent with statutory and
regulatory requirements. Authority over their direction is delegated to the consumer, for
the purpose of achieving the goals and outcomes contained in the consumer‘s plan.
The limitations associated with this delegation shall be delineated to the consumer as
part of the process of developing the plan and authorizing the individual budget.
2. An agreement shall be made in writing between the CMHSP and the consumer
delineating the responsibility and the authority of both parties in the application of the
individual budget, including how communication will occur about its use. The
agreement shall include a copy of the consumer‘s plan and individual budget. The
directions and assistance necessary for the consumer to properly apply the individual
budget shall be provided to the consumer in writing when the agreement is finalized.
123
3. An individual budget, once authorized, shall be filed with the consumer‘s approved
plan of service. An individual budget shall be in effect for a specified period of time.
Since the budget is based upon the consumer‘s plan of specialty mental health
services and supports, when the plan needs to change, the budget may need to be
reconsidered as well.
In accordance with the Person-Centered Planning Practice Guidelines, the plan may be
reopened and reconsidered whenever the consumer, or the agency, feels it needs to be
reconsidered.
4. The individual budget is authorized by the CMHSP for the purpose of providing a
defined amount of resources that may be directed by the consumer to pursue
accomplishing their plan of specialty mental health services and supports. An
individual budget shall be flexible in its use.
a. The consumer may adjust the specific application of CMHSP-authorized funds
within the budget between budgetary line items and/or categories in order to adjust
his/her specialty mental health services and supports arrangements as he or she
deems necessary to accomplish his/her plan.
b. Unless the planned adjustment deviates from the goals and objectives in the
consumer‘s plan, the consumer does not need to seek permission from the CMHSP
nor be required to provide advance notification of an intended adjustment.
c. When a consumer makes adjustments in the application of funds in an individual
budget, these shall occur within a framework that has been agreed to by the
consumer and the CMHSP, and described in an attachment to the consumer‘s selfdetermination agreement. When changes are made, these shall be promptly
communicated to the CMHSP.
d. If an adjustment in the use of the budget is intended for a service/support that
does not serve to accomplish the direction and intent of the person‘s plan, then the
plan must be appropriately modified before the adjustment may be made. The
CMHSP shall attempt to resolve such situations in an expedient manner.
e. The funds aggregated and used to finance an individual budget may be controlled by
more than one funding source. Flexibility in the use of these funds is therefore
constrained by the specific limitations of funding sources (e.g., Home Help,
Vocational Rehabilitation, etc.) Consumers must be informed when some of the
resources associated with accomplishing their plan of services and supports involve
commitments from funding sources other than the CMHSP, and assisted to work within
constraints that accompany them.
124
f. Funds allotted for specialty mental health services may not be used to purchase services
which are not specialty mental health services, nor should contracts with providers of
specialty mental health services be entered into if they are not fiscally prudent.
5. Either party -- the CMHSP or the consumer -- may terminate a self-determination
agreement, and therefore, the self-determination arrangement. Prior to the CMHSP
terminating an agreement, and unless it is not feasible, the CMHSP shall inform the
consumer of the issues that have led to consideration of a discontinuation or
alteration decision, in writing, and provide an opportunity for problem resolution.
Typically this will be conducted using the person-centered planning process, with
termination being the option of choice if other mutually-agreeable solutions cannot be
found. In any instance of CMHSP discontinuation or alteration of a self-determination
arrangement, the local processes for dispute resolution may be used to address and
resolve the issues.
6. Discontinuation of a self-determination agreement shall not, by itself, change the
consumer‘s plan of services, nor eliminate the obligation of the CMHSP to assure
specialty mental health services and supports required in the plan.
7. In any instance of CMHSP discontinuation or alteration, the consumer must be provided
an explanation of applicable appeal, grievance and dispute resolution processes and
(where required) appropriate notice.
IV.
Assuring authority over an individual budget is a core element of selfdetermination. This means that the consumer may use, responsibly, an individual
budget as the means to authorize and direct their providers of services and supports. A
CMHSP shall design and implement alternative approaches that consumers electing
to use an individual budget may use to obtain consumer-selected and directed
provider arrangements.
A. Within prudent purchaser constraints, a consumer shall be able to access any willing
and qualified provider entity that is available to provide needed specialty mental health
services and supports.
B. Approaches shall provide for a range of control options up to and including the
direct retention of consumer-preferred providers through purchase of services
agreements between the consumer and the provider. Options shall include, upon the
consumer‘s request and in line with their preferences:
1. Services/supports to be provided by an entity or individual currently operated by or
under contract with the CMHSP.
2. Services/supports to be provided by a qualified provider chosen by the consumer, with
the CMHSP agreeing to enter into a contract with that provider.
125
3. Services/supports to be provided by a consumer-selected provider with whom the
consumer executes a direct purchase-of-services agreement. The CMHSP shall
provide guidance and assistance to assure that agreements to be executed with
consumer-selected providers are consistent with applicable federal regulations
governing provider contracting and payment arrangements.
a. Consumers shall be responsible for assuring those individuals and entities selected
and retained meet applicable provider qualifications. Methods that lead to consistency and
success must be developed and supported by the CMHSP.
b. Consumers shall assure that written agreements are developed with each provider
entity or individual that specify the type of service or support, the rate to be paid, and
the requirements incumbent upon the provider.
c. Copies of all agreements shall be kept current, and shall be made available by the
consumer, for review by authorized representatives of the CMHSP.
d. Consumers shall act as careful purchasers of specialty mental health services and
supports necessary to accomplish their plan. Arrangements for purchasing services
shall not be excessive in cost. Consumers should aim for securing a better value in
terms of outcomes for the costs involved. Existing personal and community resources
shall be pursued and utilized before using public mental health system resources.
e. Fees and rates paid to providers with a direct purchase-of-services agreement with
the consumer shall be negotiated by the consumer, within the boundaries of the
consumer‘s authorized individual budget. The CMHSP shall provide guidance as to
the range of applicable rates, and may set maximum amounts that a consumer may
spend to pay specific providers.
4. A consumer shall be able to access alternative methods to choose, control and direct
personnel necessary to provide direct support, including:
a. Acting as the employer of record of personnel.
b. Access to a provider entity that can serve as employer of record for personnel
selected by the consumer.
c. CMHSP contractual language with provider entities that assures consumer
selection of personnel, and removal or reassignment of personnel who fail to meet
consumer preferences.
d. Use of CMHSP-employed direct support personnel, as selected and retained by
the consumer.
126
5. A consumer participating in self-determination shall not be obligated to utilize CMHSPemployed direct support personnel or a CMHSP-operated or -contracted program/service.
6. All individuals selected by the consumer, whether she or he is acting as employer of
record or not, shall meet applicable provider requirements for direct support personnel,
or the requirements pertinent to the particular professional services offered by the
provider.
7. A consumer shall not be required to select and direct needed provider entities or his/her
direct support personnel if she or he does not desire to do so.
IV. A CMHSP shall assist a consumer participating in self-determination to select,
employ, and direct his/her support personnel, to select and retain chosen qualified
provider entities, and shall make reasonably available, consistent with MDCH
Technical Advisory instructions, their access to alternative methods for directing and
managing support personnel.
A. A CMHSP shall select and make available qualified third-party entities that may
function as fiscal intermediaries to perform employer agent functions and/or provide other
support management functions, in order to assist the consumer in selecting, directing and
controlling providers of specialty services and supports.
B. Fiscal intermediaries shall be under contract to the CMHSP or a designated subcontracting entity. Contracted functions may include:
1. Payroll agent for direct support personnel employed by the consumer (or chosen
representative), including acting as an employer agent for IRS and other public
authorities requiring payroll withholding and employee insurances payments.
2. Payment agent for consumer-held purchase-of-services and consultant agreements
with providers of services and supports.
3. Provision of periodic (not less than monthly) financial status reports concerning the
individual budget, to both the CMHSP and the consumer. Reports made to the
consumer shall be in a format that is useful to the consumer in tracking and
managing the funds making up the individual budget.
4. Provision of an accounting to the CMHSP for the funds transferred to it and used to
finance the costs of authorized individual budgets under its management.
5. Assuring timely invoicing, service activity and cost reporting to the CMHSP for specialty
mental health services and supports provided by individuals and entities that have a
direct agreement with the consumer.
127
6. Other supportive services, as denoted in the contract with the CMHSP, that
strengthen the role of the consumer as an employer, or assist with the use of other
agreements directly involving the consumer in the process of securing needed services.
C. A CMHSP shall assure that fiscal intermediary entities are oriented to and
supportive of the principles of self-determination, and able to work with a range of
consumer styles and characteristics. The CMHSP shall exercise due diligence in
establishing the qualifications, characteristics and capabilities of the entity to be
selected as a fiscal intermediary, and shall manage the use of fiscal intermediaries
consistent with MDCH Technical Assistance Advisories addressing fiscal
intermediary arrangements.
D. An entity acting as a fiscal intermediary shall be free from other relationships
involving the CMHSP or the consumer that would have the effect of creating a conflict of
interest for the fiscal intermediary in relationship to its role of supporting consumerdetermined services/supports transactions. These other relationships typically would
include the provision of direct services to the consumer. The CMHSP shall identify and
require remedy to any conflicts of interest of the entity that, in the judgment of the CMHSP,
interfere with the performance of its role as a fiscal intermediary.
E. A CMHSP shall collaborate with and guide the fiscal intermediary and each
consumer involved in self-determination to assure compliance with various state and
federal requirements and to assist the consumer in meeting his/her obligations to
follow applicable requirements. It is the obligation of the CMHSP to assure that the
entities selected to perform intermediary functions are capable of meeting and
maintaining compliance with the requirements associated with their stated functions,
including those contained in relevant MDCH Technical Assistance Advisories.
F. Typically, funds comprising a consumer‘s individual budget would be lodged with
the fiscal intermediary, pending appropriate direction by the consumer to pay
consumer-selected and contracted providers. Where a consumer selected and
directed provider of services has a direct contract with the CMHSP, the provider may be
paid by the CMHSP, not the fiscal intermediary. In that case, the portion of funds in the
individual budget would not be lodged with the fiscal intermediary, but instead would
remain with the CMHSP, as a matter of fiscal efficiency.
Definitions
Fiscal Intermediary: A fiscal Intermediary is an independent legal entity
(organization or individual) that acts as a fiscal agent of the CMHSP for the purpose of
assuring fiduciary accountability for the funds comprising a consumer‘s individual
budget. A fiscal intermediary shall perform its duties as specified in a contract with a
CMHSP or its designated sub-contractor.
128
The purpose of the fiscal intermediary is to receive funds making up a consumer‘s
individual budget, and make payments as authorized by the consumer to providers
and other parties to whom a consumer using the individual budget may be obligated. A
fiscal intermediary may also provide a variety of supportive services that assist the
consumer in selecting, employing and directing individual and agency providers.
Examples of entities that might serve in the role of a fiscal intermediary include:
bookkeeping or accounting firms; local ARC or other advocacy organizations; a
subsidiary of a service provider entity if no conflict of interest exists.
Qualified Provider: A qualified provider is an individual worker, a specialty
practitioner, professional, agency or vendor that is a provider of specialty mental
health services or supports that can demonstrate compliance with the requirements
contained in the contract between the Department of Community Health and the
CMHSP, including applicable requirements that accompany specific funding sources,
such as Medicaid. Where additional requirements are to apply, they should be
derived directly from the consumer‘s person-centered planning process, and should be
specified in the consumer‘s plan, or result from a process developed locally to assure
the health and well-being of consumers, conducted with the full input and involvement of
local consumers and advocates.
Consumer: For the purposes of this policy, ―Consumer‖ means the adult consumer of
direct specialty mental health services and supports, and/or his/her selected
representative. That is, the consumer may select a representative to enter into the selfdetermination agreement and for other agreements that may be necessary for the
consumer to participate in consumer-directed supports and services arrangements.
Where the consumer has a legal guardian, the role of the guardian in self-determination
shall be consistent with the guardianship arrangement established by the court. A
person selected as the representative of the consumer shall not supplant the role of
the consumer in the process of person-centered planning, in accordance with the
Mental Health Code and the requirements of the contract between the CMHSP and
the Department of Community Health. Where a consumer has been deemed to require
a legal guardian, there is an extra obligation on the part of the CMHSP and those close
to the consumer to assure that it is the consumer‘s preferences and dreams that drive
the use of self-determination arrangements, and that the best interests of the
consumer are primary. A CMHSP shall have the discretion to limit or restrict the use of
self-determination arrangements by a guardian when the planned or actual use of
those arrangements by that guardian are in conflict with the expressed goals and
outcomes of the consumer.
Individual Budget: An individual budget is a fixed allocation of public mental health
resources, and may also include other public resources whose access involves the
assistance of the CMHSP, denoted in dollar terms. These resources are agreed upon as
the necessary cost of specialty mental health services and supports needed to
accomplish a consumer‘s plan of services/supports.
129
The consumer served uses the funding authorized to acquire, purchase and pay for
specialty mental health services and supports that support accomplishment of the
consumer‘s plan.
Plan: A plan means the consumer‘s Individual Plan of Services and/or Supports, as
developed using a person-centered planning process.
CMHSP: For the purposes of this policy, a Community Mental Health Services
Program is an entity operated under Chapter Two of the Michigan Mental Health
Code, or an entity under contract with the CMHSP and authorized to act on its behalf in
providing access to, planning for, and authorization of specialty mental health services
and supports for people eligible for mental health services.
Specialty Mental Health Services: This term includes any service/support that can
legitimately be provided using funds authorized by the CMHSP in the individual
budget. It includes alternative services and supports as well as Medicaid-covered
services and supports.
Choice Voucher System: The Choice Voucher System is the designation for set of
arrangements that facilitate and support accomplishing self-determination, through the
use of an individual budget, a fiscal intermediary, and direct consumer-provider
contracting. Its use shall be guided by MDCH Technical Assistance Advisories which may
be issued from time to time by the Department.
Self-Determination: Self-determination incorporates a set of concepts and values that
underscore a core belief that people who require support from the public mental health
system as a result of a disability should be able to define what they need in terms of the
life they seek, have access to meaningful choices, and have control over their lives. Within
Michigan‘s public mental health system, self-determination involves accomplishing system
change to assure that services and supports for people are not only person-centered, but
person-defined and person-controlled. Self-determination is based on four principles.
These principles are:
Freedom: The ability for individuals, with assistance from significant others (e.g.,
chosen family and/or friends), to plan a life based on acquiring necessary supports in
desirable ways, rather than purchasing a program. This includes the freedom to
choose where and with whom one lives, who and how to connect to in one‘s
community, the opportunity to contribute in one‘s own ways, and the development of a
personal lifestyle.
Authority: The assurance for a person with a disability to control a certain sum of dollars
in order to purchase these supports, with the backing of their significant others, as
needed. It is the authority to control resources.
130
Support: The arranging of resources and personnel, both formal and informal, to assist
the person in living his/her desired life in the community, rich in community associations
and contributions. It is the support to develop a life dream and reach toward that dream.
Responsibility: The acceptance of a valued role by the person in the community
through employment, affiliations, spiritual development, and caring for others, as well as
accountability for spending public dollars in ways that is life-enhancing. This includes
the responsibility to use public funds efficiently and to contribute to the community
through the expression of responsible citizenship. A hallmark of self- determination is
assuring a person the opportunity to direct a fixed amount of resources, which is
derived from the person-centered planning process and called an individual budget. The
person controls the use of the resources in his/her individual budget, determining, with
the assistance of chosen allies, which services and supports he or she will
purchase, from whom, and under what circumstances. Through this process, they
possess power to make meaningful choices in how they live their life.
Housing Best Practice Guidelines
[From the contract between CMH, Community Mental Health, and DCH, Michigan Dept. of
Community Health.]
I. Summary
This guideline establishes policy and procedure for ensuring that the provision of
mental health services and supports are not affected by where consumers choose to
live: their own home, the home of another or in a licensed setting. In those instances
when public money helps subsidize a consumer‘s living arrangement, the housing unit
selected by the consumer shall comply with applicable occupancy standards.
II. Application
A. Psychiatric hospitals operated by the Michigan Department of Community Health
(MDCH).
B. Regional centers for developmental disabilities operated by MDCH.
C. Special facilities operated by MDCH.
D. Residential placement agencies operated by MDCH.
E. Community Mental Health Services Programs (CMHSPs) as specified in their master
contract with MDCH.
III. Policy
131
The Michigan Department of Community Health recognizes housing to be a basic
need and affirms the right of all consumers of public mental health services to pursue
housing options of their choice.
Just as consumers living in licensed dependent settings may require many different
types of services and supports, persons living in their own homes or sharing their
household with another may have similar service needs. RMHA‘s [Responsible Mental
Health Agency] shall foster the provision of services and supports independent
[regardless] of where the consumer resides.
When requested, RMHAs shall educate consumers about the housing options and
supports available, and assist consumers in locating habitable, safe, and affordable
housing. The process of locating suitable housing shall be directed by the
consumer‘s interests, involvement and informed choice. Independent housing
arrangements in which the cost of housing is subsidized by the RMHA are to be
secured with a lease or deed in the consumer‘s name.
This policy is not intended to subvert or prohibit occupancy in or participation with
community based treatment settings such as an adult foster care home when needed
by an individual recipient.
IV. Definitions
Affordable: is a condition that exists when an individual‘s means or the combined
household income of several individuals is sufficient to pay for food, basic clothing, health
care, and personal needs and still have enough left to cover all housing related costs
including rent/mortgage, utilities, maintenance, repairs, insurance and property taxes. In
situations where there are insufficient resources to cover both housing costs and basic
living costs, individual housing subsidies may be used to bridge the gap when they are
available.
Habitable and safe: means those housing standards established in each community
that define and require basic conditions for tenant/resident health, security, and
safety.
Housing: refers to dwellings that are typical of those sought out and occupied by
members of a community. The choices a consumer of mental health services makes in
meeting his or her housing needs are not to be linked in any way to any specific program
or support service needs he or she may have.
Responsible Mental Health Agency (RMHA): means the MDCH hospital, center or
CMHSP responsible for providing and contracting for mental health services and/or
arranging and coordination the provision of other services to meet the consumers‘
needs.
132
V. STANDARDS
RMHAs shall develop policies and create mechanisms that give predominant
consideration to consumers‘ choice in selecting where and with whom they live. These
policies and mechanisms shall also:
A. Ensure that RMHA-supported housing blends into the community. Supported
housing units are to be scattered throughout a building, complex, or the community in
order to achieve community integration when possible. Use of self-contained campuses
or otherwise segregated buildings as service sites is not the preferred mode.
B. Promote and support home ownership, individual choice, and autonomy. The
number of people who live together in RMHA-supported housing shall not exceed the
community‘s norms for comparable living settings.
C. Assure that any housing arranged or subsidized by the RMHA is accessible to the
consumer in compliance with applicable state and local standards for occupancy,
health, and safety.
D. Be sensitive to the consumer‘s cultural and ethnic preferences and give consideration
to them.
E. Encourage and support the consumer‘s self-sufficiency.
F. Provide for ongoing assessment of the consumer‘s housing needs.
G. Provide assistance to consumers in coordinating available resources to meet their
basic housing needs. RMHAs may give consideration to the use of housing subsidies
when consumers have a need for housing that cannot be met by the other resources
which are available to them.
VI. References and Legal Authority
MCL 330.1116(j).
VII. Exhibits
Federal Housing Subsidy Quality Standards based on 24 CFR § 882.10.
Housing occupied by a consumer of the Supported Community Living Program must
meet the following minimum environmental standards as interpreted by MDCH based
on 24 CFR § 882.10 [Housing Quality Standards]. Such housing standards shall
serve as an example of standards that should be considered when seeking federally
subsidized housing.
133
Every unit must have at least a living room, kitchen and bath. A one-room efficiency
with a kitchen may be utilized provided there is a private bath.
The ceilings, walls and floors of each room should be in good condition; cracks,
bulges, holes, and floor coverings that might cause someone to trip are unacceptable
as is lead paint.
Each room must have at least one window that opens to the outside except for the
bath where a working exhaust fan may substitute for a window. All windows designed to
be operable and should open easily. All operable windows and doors that can be
reached from the outside, a common public hallway, a fire escape, porch or other outside
place that can be reached from the ground, must have a working lock.
The living room should have at least two wall mounted electrical outlets, or one outlet
and one permanent overhead light fixture. The kitchen should have at least one
electrical outlet and one permanent light fixture; the bath at least one permanent
overhead or wall light fixture. Both the kitchen and bath electrical outlets must have
ground fault interrupters. Table, floor and ceiling lamps plugged into sockets and
extension cords do not count; they are not permanent. Broken or frayed wiring,
fixtures hanging from wires with no other firm support (such as a chain), missing
cover plates on switches or outlets and badly cracked outlets are not acceptable.
Both the kitchen and bath must have hot and cold running water. A bathroom sink may
not be used in place of a kitchen sink and vice versa. The bathroom should have a tub
or shower with hot and cold running water and a toilet that works.
Single units must have at least two unobstructed means of egress. Units in apartment
complexes should have an entrance from the outside or from a public hall so that it is
not necessary to go through anyone else‘s living space to get into the unit.
There shall be an operating smoke detector adjacent to each sleeping area with
appropriate maintenance procedures in place to keep each detector continuously
operational.
If the unit is in an apartment building with elevators or stairwells, the former should be
safe and work properly and the latter well lit and have railings. Any length of stairs
(e.g., generally more than four steps), and porches, balconies or decks more than 30
inches above ground should have secure handrails attached.
The building foundation should have no serious leaks and the plumbing and sewage
systems must be served by an approved public or private water supply system. The
roof should not leak and the gutters and downspouts, if present, should be securely
attached to the building.
134
Roof leaks can usually be detected by checking for stains on the ceiling inside the
building.
The chimney should not lean or have big cracks or missing bricks, the water pipes
should be in good condition with no leaks and no serious rust that causes the water to
be discolored, the water heater should be equipped and installed in a safe manner,
and the heating equipment should be adequate to provide sufficient heat to keep the unit
warm during cold months. Spacer heaters (or room heaters) that burn oil or gas and are
not vented to a chimney are not acceptable. Space heaters that are vented are
acceptable if they provide sufficient heat.
If the service site is a mobile home, it must be placed on the site in a stable manner so
as to be free from hazards such as sliding or wind damage, and there must be at least
one operating smoke detector in the home with appropriate maintenance procedures in
place to keep it continuously operational.
135