LMHAs and MHR/TCM Providers: Quarterly Retrospective Review Process
Date: 02/18/22
As a reminder, Superior HealthPlan conducts quarterly retrospective reviews for Local Mental Health Authorities (LMHAs) and multi-specialty groups delivering Mental Health Rehabilitative Services and Targeted Case Management (MHR/TCM) services to Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) members. This review process is conducted to ensure providers of these services meet all training requirements and use the Department of State Health Services (DSHS) Resilience and Recovery Utilization Management Guidelines (RRUMG).
- Annual MHR/TCM Provider Attestation Required
- LMHAs and MHR/TCM providers must submit an annual attestation via email to: ProviderCertifications@SuperiorHealthPlan.com
- Providers can access the SB58 Attestation Form (PDF) under the Credentialing section on Superior’s Provider Forms webpage.
- Timely submission of this annual attestation is a pre-requisite for delivery and reimbursement of MHR/TCM services.
- Superior HealthPlan Retrospective Review Process
- Details and clarification of the existing retrospective review process, as well as recent updates to this process are included below.
- Service Delivery Requirements
- Providers delivering services to children must have an active and current Child and Adolescent Needs and Strengths (CANS) certification.
- Providers delivering services to adults must have the Adult Needs and Strengths Assessment (ANSA) certification.
- Providers must not deliver services to members without an Active CANS/ANSA in the Department of State and Health Services Clinical Management for Behavioral Health Services (CMBHS) Web-Based System.
- Members cannot receive MHR or TCM services from multiple providers simultaneously. Only one LMHA or MHR/TCM provider can have an Active assessment in the CMBHS system and provide services to a member during a specified timeframe.
- If a member changes their MHR/TCM provider, the previous provider must discharge the assessment so the new provider can begin an assessment in CMBHS system.
- For assistance with the CMBHS system, providers can call the HHS CMBHS Help Line at 1-866-806-7806. For additional information, please visit the HHS CMBHS webpage.
- Documentation Requirements
- LMHAs and MHR/TCM providers must submit ANSA and CANS assessments for services within the date span requested of the retrospective review for each applicable case.
- CANS and ANSA assessments must be printed directly from the CMBHS system.
- Assessments must be in Active, Closed and Complete status with each chart request.
- To verify compliance, Draft status assessments are not accepted.
- Clinical Documentation Due Date (Update)
- Providers will work with their Superior Utilization Manager to collect requested documentation and set up a feedback meeting. Providers will receive the due date for requested clinical documentation (recovery plans, assessments, etc.) with at least one to two weeks’ notice. Providers can anticipate that the documentation will be requested at least one to two weeks in advance of the scheduled feedback meeting to review the audit results.
- Based on provider feedback, Superior has implemented the following updates to this process:
- The Superior Utilization Manager will share the audit feedback with the provider two Business Days in advance of the feedback meeting, including scores based on current documentation and a list of the documentation that was not provided in the case files for that audit.
- Any missing documentation must be submitted by close of business on the date of the feedback meeting.
- The additional documentation will be reviewed and incorporated into the final audit score.
- Report Findings and Rebuttal Process
- Superior will complete the review of the clinical documentation within two weeks of receipt, and subsequently conduct the feedback meeting with the provider to review the retrospective review findings. Please note:
- If a provider chooses to submit a rebuttal, Superior must receive their comments (which can be provided on the feedback form) within ten business days of the feedback meeting.
- If Superior does not receive the rebuttal within ten business days of the feedback meeting, Superior will not be able to consider the rebuttal for the quarter’s review.
- Based on Superior’s review of the rebuttal, Superior will forward the final report to the provider within 30 calendar days of the rebuttal submission.
- Superior will complete the review of the clinical documentation within two weeks of receipt, and subsequently conduct the feedback meeting with the provider to review the retrospective review findings. Please note:
- Identification and Recovery of Identified Overpayments
- Upon finalization of the retrospective review, all billed services that are not supported by the clinical documentation submitted from the provider will be classified as inaccurate billing, and if those services were previously paid, subject to recovery of the overpayment. Providers who receive a letter regarding overpayment will have the opportunity to submit an appeal to dispute the applicable findings.
- Examples of claim overpayments include, but are not limited to:
- Missing documentation for services billed.
- Billing two services concurrently (overlapping services billed).
- Billing for transportation.
- Billing without an Active CANS/ANSA or recovery plan on file.
- Billing without the provider rendering the service having an Active CANS/ANSA certification.
- Billing for an incorrect service (i.e., skills training billed as case management, crisis intervention services billed for a stay in an extended observation unit).
- Billing for skills training without using a state-approved curriculum.
- Billing for unbillable activities (i.e., shopping or watching movies).
- Please reference the billing guidelines found on the HHS Local Mental Health Authorities webpage.
- Schedule and Frequency of Retrospective Reviews
- Superior will waive the next scheduled quarterly audit for providers who demonstrate a chart compliance score equal to or greater than 80%, and demonstrate a claims compliance score equal to or greater than 95% in two consecutive quarterly audits. Beginning in 2022, the Superior Utilization Manager will notify the provider in the feedback meeting, if the provider is eligible to waive the next quarter’s review, based on demonstrated compliance in the prior two quarters.
- Alternatively, providers who do not meet the minimum 80% chart compliance threshold nor the 95% claims compliance thresholds two consecutive quarters, may be placed on a corrective action plan. Superior will notify the provider of non-compliance during the feedback meeting. The provider will have the opportunity to remediate the identified deficiencies. Providers placed on corrective action must successfully complete the corrective action plan in the timeframe specified during the feedback meeting.
For any questions about the retrospective review process, please contact your assigned Utilization Manager.