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24.3.19.1 Authorization
Non-Face-to-Face Clinician-Directed Care Coordination Services
Authorization is required. A CSHCN Services Program Authorization Request for Non-Face-to-Face Clinician-Directed Coordinated Care Services and the required documentation must be submitted.
• Authorization of initial non-face-to-face clinician-directed care coordination services requires at least one covered face-to-face inpatient or outpatient E/M visit by the clinician directing the care coordination during the six months preceding the provision of the first non-face-to-face care coordination service.
•Authorization for subsequent non-face-to-face clinician-directed care coordination services requires at least one covered face-to-face inpatient or outpatient E/M visit by the clinician directing the care coordination during the previous 12 months, or more frequently as indicated by the client's condition.
Authorization of medical team conferences (procedure codes 1-99361 and 1-99362) is limited to once every six months. Additional medical team conferences may be considered with documentation of a change in the client's medical home.
Authorization of non-face-to-face prolonged services (procedure codes 1-99358 and 1-99359) is limited to a maximum of 90 minutes once per client per provider. Additional prolonged non-face-to-face services may be authorized if there is one of the following significant changes in the client's clinical condition:
•The client will soon be, or has recently been, discharged from a prolonged and complicated hospitalization requiring coordination of complex care with multiple providers in order for the client to be adequately cared for in the home.
•Documentation of recent trauma resulting in new medical complications that require complex interdisciplinary care.
•The client has a new diagnosis of a medically complex condition requiring additional interdisciplinary care with additional specialists.
Authorization of care plan oversight or supervision (procedure codes 1-99339, 1-99340, 1-99374, 1-99375, 1-99377, and 1-99378) is limited to a maximum of two services per six-month authorization period.
In order for authorization to be considered, the client must require complex and multidisciplinary care modalities involving regular clinician development and/or revision of care plans, review of subsequent reports of client status, and review of related laboratory and other studies.
•Medically complex health-care: Health-care provided by a clinician that requires coordination of various treatment modalities and/or a multidisciplinary approach due to the client's moderate or severe health condition, physical or functional limitations, and/or health risk factors.
•Multidisciplinary health-care: The coordination of clinician-ordered medically necessary health-care that requires the collaboration of two or more medical, educational, social, developmental, or other professionals in order properly to devise and implement the clinician-developed plan of medical care. For CSHCN Services Program coverage, multidisciplinary health-care must include medically necessary services provided by program-enrolled clinical providers. Development and implementation of the plan of medical care may, in addition, need to take into account other related care provided by nonclinical providers as required to address the overall health needs of a client.
Documentation of the following components must be submitted with the authorization form to obtain an initial authorization or renewal:
•A current medical summary, containing key information about the client's health (e.g. conditions, complexity, medications, allergies, past surgical procedures, etc.).
•A current list of the main concerns as well as key strengths and assets, and the related current clinical information.
•Planned action steps or interventions to address the concerns and to sustain or build strengths, with the expected outcomes.
•Persons responsible.
•Timeframes or due dates.
The supporting documentation can be in the form of:
•Formal written care plan.
•Progress note detailing the care coordination planning.
•Letter of medical necessity detailing the care plan oversight and care coordination.
Authorization is limited to a maximum of six months. Subsequent periods of authorization require submission of a new request with documentation supporting medical necessity for ongoing services.
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