CPST Prior Authorization Requests
Permedion is responsible for reviewing the medical necessity of all community psychiatric supportive treatment (CPST) Prior Authorization requests. It is our intention to make this process as simple and expedient as possible, while effectively addressing the unique needs of both providers and recipients. The following information will be helpful in understanding how to proceed.
In order for Permedion to process a CPST Prior Authorization request, both a clinical documentation form and the recipient’s individualized service plans for up to one year prior to the request date must be received. If any of these documents are missing, processing will be delayed.
The quality and quantity of documentation provided for Utilization Review potentially influences both the timeliness of processing and an agency’s CPST prior authorization approval rate. It is to the advantage of providers to present a clinical picture that adequately reflects recipient need, as well as the specific benefit derived as a result of CPST. Using the CPST Prior Authorization Request form, providers must well establish the medical necessity of treatment.
Individualized Service Plans
Individualized Service Plans (ISPs) provide Permedion with additional information about how services are both utilized and related to medical necessity. ISPs for up to one year prior to the CPST Prior Authorization request must be included with all submissions.
CPST Prior Authorization Request forms must always be newly written and based upon current assessment. Permedion cannot accept for Utilization Review cut and pasted information from previously submitted requests. The following are additional quality guidelines:
- Clearly answer all questions. Ensure that questions and answers are congruent.
- Avoid generalizations. Give numerous individualized examples of client functioning, as well as the CPST interventions and functions provided by your agency.
- When there is an increase in service, provide details as to why it is necessary.
- Remember that only CPST functions can be approved and billed under CPST. Ensure that documentation indicates CPST functions only, e.g., therapy, nursing, and transportation are not covered by CPST.
- Provide only information relevant to the patient’s current service needs.
- Correctly provide all recipient identifying information, as well as the agency 10-digit NPI number.
- Ensure that intervention examples include a teaching modality.
- Particularly when the recipient is a dependent, include information about how parents and guardians are engaged in treatment.
- Word process the request forms, otherwise they will not be accepted for review.
The amount of information provided on the CPST Prior Authorization Request form is at the discretion of providers. However, it is recommended that care be taken to ensure a quantity sufficient to support medical necessity. The expandable fields should be well utilized. Typically, more information is better, however, ensuring that it is relevant to the current request.
The primary purpose of Permedion Utilization Review is to determine medical necessity. Permedion encourages providers to regularly review with employees what constitutes medically necessary services, as well as how to adequately document medical necessity on the CPST Prior Authorization Request form.
Ohio Administrative Code (OAC) regulation 5160-1-01 both defines and provides the guiding principles for Medicaid Medical Necessity.
CPST OAC Regulation
OAC regulation is specific regarding what functions and interventions constitute CPST. Permedion encourages providers to regularly review the regulation with employees.
Ohio Administrative Code (OAC) regulation 5122-29-17 both defines and provides the guiding principles for CPST.
CPST Prior Authorization Form
In order for Permedion to provide utilization review, a CPST Prior Authorization form must be downloaded and completed. Because it is important that providers always use the most current form, it is recommended that a new one always be downloaded when preparing a request. Additionally, when getting onto the website, press F5 on the computer keyboard in order to clear cookies.
Utilization Review Process for CPST Prior Authorization Requests
It is advantageous for providers to be knowledgeable of the process related to making CPST Prior Authorization requests. Not only does it aid in knowing what to expect from Permedion, but also enables a facility to develop internal procedures for best managing the precertification needs of their recipients. The following is the Utilization Review process for CPST Prior Authorization requests:
- Download and complete the CPST Prior Authorization Request form.
- Using 855-974-5394, fax Permedion the CPST Prior Authorization Request form along with ISPs for up to one year prior. Multiple cases must be faxed separately.
- The Permedion social worker reviewer receives the CPST Prior Authorization Request form. A determination will be made within three (3) business days.
- When a CPST Prior Authorization request is approved, a letter indicating such will be mailed to the recipient, as well as the agency clinical and billing contacts.
- When a CPST Prior Authorization request is denied a letter will be mailed to the recipient, as well as the provider clinical and billing contacts. The recipient letter will provide information on how the recipient can, within 90 days, appeal the decision through a state hearing.
Recipient Hearing Process
When a denial for CPST services is rendered, the Medicaid recipient has the right to a state hearing. In every recipient denial letter there is a “Notice of Medical Determination and Right to State Hearing.” Recipient hearings are administered by the Office of Medical Assistance (OMA). Below is the recipient hearing process:
- The recipient has 90 days from the denial effective date (the date of the letter) to request a hearing.
- The Bureau of State Hearings will notify Permedion of the recipient request and submit a completed “Appeals Summary” form to the District Hearing Section.
- OMA will determine when a hearing will take place.
- The hearing date and time will be issued by the District Hearing Section at least 10 calendar days prior to the hearing.
- The hearing takes place.
- The District Hearing Officer notifies Permedion of the final determination.
- Permedion documents the hearing decision in the case record, then completes and submits a “State Hearing Compliance” form to OMA and the district office. If the denial was overturned, Permedion will process the approval and send letters indicating such to the recipient, as well as the provider clinical and billing contacts.
CPST Utilization in MITS
Providers have the capacity to view in Ohio Medical Information Technology System (MITS) how many of a recipient’s initial 104 hours of CPST have been paid out in claims within the state fiscal year (SFY). This can be useful for an agency, however, it is important to note that another provider may also be billing CPST hours, an agency where a recipient previously received CPST may still have claims that will be submitted, and the total CPST hours that show as available are only as accurate as the last claim that was processed.
Please click here for the process on how to check a recipient’s CPST utilization in MITS.
MyCare Ohio CPST Prior Authorization
CPST recipients who receive full benefits from both Medicare and Medicaid, are older than age 18 and reside in a MyCare service region are enrolled in an Ohio MyCare plan with one of five managed care companies in the state of Ohio. When a mental health provider determines that a CPST prior authorization request needs to be made for a MyCare enrollee, the provider must seek prior authorization through the managed care company, rather than Permedion. Each managed care company has their own individually established documentation needs and procedure requirements.
Protected Health Information
CPST Prior Authorization requests should not include the entire medical record. Personal health information (PHI) is protected by law in order to support patient privacy, therefore, it is of great importance that Permedion and providers work together to ensure that unnecessary records not be shared.
A central aspect of the privacy rule is the principle of “minimum necessary use” and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of PHI needed to accomplish the intended purpose. A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum necessary standard applies, a covered entity may not use, disclose or request the entire medical record unless it can be specifically justified.
Taking the privacy rule into account, Permedion does not request providers to send full medical records for CPST Prior Authorization requests