Prior Authorization : Approval Criteria

Approval Criteria for Initial Prior Authorization Requests

An initial PA request is the first request to ForwardHealth for coverage of services for a member for an episode of behavioral treatment, even if the member's behavioral treatment is already in progress but covered by a payer other than Wisconsin Medicaid.

Initial PA requests for behavioral treatment services should be submitted for no more than six months of treatment. The authorization period granted may be shorter or longer than the request, depending on individual circumstances related to the demonstration of medical necessity.

The following information is required to make a determination of medical necessity for an initial PA request:

• Diagnostic evaluation
• Provider's initial assessment
• Previous treatment history
• Age-Normed testing results
• Behavioral treatment team
• POC with notes on any medical conditions
• Care collaboration plan
• Supporting documentation

Simplified requirements for comprehensive behavioral treatment PA requests for members who have not yet reached 6 years of age are available.

Diagnostic Evaluation

Diagnostic evaluation, which includes both psychological and neuropsychological testing, is covered under the ForwardHealth mental health benefit when performed by a Medicaid-enrolled licensed physician or psychologist. A diagnostic report is required to be submitted with the PA request.

For comprehensive behavioral treatment, the diagnostic report must be dated within one year of the PA request, or for individuals continuously enrolled in a behavioral treatment program prior to the PA request, within one year of the onset of the member's current course of treatment.

For focused behavioral treatment, diagnostic reports dated more than one year prior to the PA request are acceptable. However, the provider is required to include an updated clinical impression of the member's diagnostic status in the initial assessment.

ForwardHealth requires documentation of the following elements in the diagnostic report:

• Detailed interview regarding developmental, medical, family, educational, and intervention history
• Use of a diagnostic tool that is validated in peer-reviewed clinical literature and appropriate for the condition being evaluated, and which is administered according to protocol (For example for ASD, the ADOS-2, ADI-R, and CARS-2 are examples of validated tools appropriate for diagnosing autism.)
• Direct observation of the member, including written descriptions of clinical observations
• Direct probing of the member to assess specific skills, including descriptions of findings
• Review of relevant records (for example, medical, school IEP, outside therapies)
• Consultation with other professionals, for members with comorbid medical or mental health conditions that may contribute to the presenting symptoms
• Discussion of additional symptoms, possible or actual comorbid conditions, and differential diagnosis

If documentation in the member's medical record indicates potential or actual co-morbid conditions that could impact behavioral treatment, and that are not adequately clarified in the diagnostic report, ForwardHealth may request an independent diagnostic evaluation.

Provider's Initial Assessment

The provider requesting behavioral treatment services is required to submit their written initial assessment of the member, completed prior to the current course of behavioral treatment. If the initial assessment is more than three months old, or if the member has participated in behavioral treatment since the initial assessment, the requesting provider should include a brief addendum describing the member's current strengths, functional skills, limitations, and behavioral concerns, as well as updates on any background details that have changed. The initial assessment must include:

• The member's developmental and medical history.
• The member's current living arrangements and family supports.
• The member's current school or vocation.
• The member's current array of treatments and supportive services.
• Past mental health or behavioral health treatment and outcomes.
• The member's strengths and functional skills, including the provider's observations.
• The member's limitations and behavioral concerns, including the provider's observations.
• Appropriateness of the provider's treatment approach for meeting the member's demonstrated needs.
• Discussion of any factors that may impact the member's response to treatment.

The requesting provider's current clinical impression of the member's diagnostic status must be included when the member's diagnostic report is dated more than one year prior to the PA request. When the member's records indicate differences of opinion among professionals who have evaluated or treated the member for conditions related to the diagnosis, the requesting provider is required to address and reconcile these differences in the initial assessment.

Previous Treatment

PA requests must include information about all treatments previously received by the member and related to the member's current deficits. This includes, but is not limited to, behavioral treatment, SLP, OT, PT, daily living skills training, and psychotherapy.

Based on information collected from the member, member's caregivers, or the member's records, the requesting provider is required to indicate the effectiveness of previous interventions and the reason for discontinuing the interventions (for example, aged out, goals mastered). If response to intervention was complex, the requesting provider should summarize the member's outcomes in the initial assessment.

Age-Normed Testing Results

Age-Normed testing or other formal assessments are required to establish the member's baseline prior to the provision of treatment, and may be required to evaluate progress periodically. Different types of testing are required for comprehensive and focused treatment.

Providers should submit all age-normed testing results, when available. However, if cognitive test results are not available, ForwardHealth will adjudicate the PA request without the test results. ForwardHealth requires cognitive testing only when needed to establish medical necessity.

Comprehensive Treatment

The member's developmental age norms should be assessed across a range of skill areas to include cognitive functioning (for example, IQ, developmental age equivalents), communication skills (for example, receptive and expressive language measures), and adaptive behavior (for example, socialization, motor functioning, life skills). Age-Normed testing to establish the member's baseline developmental level is required prior to the provision of treatment. ForwardHealth requires age-normed tests to meet the following standards:

• The member's age is within the test's published age range.
• The test is administered by a qualified professional, following standard administration procedures.
• The test is published and has been subject to rigorous psychometric evaluation and age-norming procedures.
• The test measures one or more specific areas of individual performance (for example, IQ, cognition, communication, adaptive behavior).
• Scores (composite or subscales) are reported as standard scores, percentiles, or age scores.

Recent assessment reports completed by qualified professionals from other agencies or school districts may be submitted. Behavioral identification assessment (CPT code 97151) and behavior identification-supporting assessment (CPT code 97152) are covered services that may be used by the requesting provider to complete baseline testing prior to submitting a PA request for treatment and for periodic reassessments during the member's course of treatment.

ForwardHealth does not routinely require annual re-testing on age-normed measures but may require periodic reassessments when needed to establish the medical necessity of a requested service.

Focused Treatment

The member's specific skill limitations (for example, tolerating change, social communication skills, self-care skills) should be assessed using standardized measures, or as appropriate, an FBA should be completed to identify the function of the problem behavior and develop an effective treatment protocol. Recent standardized assessment reports completed by qualified professionals from other agencies or school districts may be submitted. FBAs must be current and conducted by the requesting provider. When previous efforts at behavior change have been unsuccessful for very challenging behavior (for example, aggression, self-injury, destructive behavior), a functional analysis of behavior may be required. Behavioral identification assessment (CPT code 97151) and behavior identification-supporting assessment (CPT code 97152) are covered services that may be used by the requesting provider to complete this testing or assessment prior to submitting a PA request for treatment and for periodic re-assessment for treatment planning.

If the only service requested is family adaptive behavior treatment guidance (CPT code 97156), standardized testing may be omitted from the PA request.

Behavioral Treatment Team

The provider is required to establish that the treatment team's skills and experience are adequate and appropriate for the member's assessed needs, and that unlicensed staff will receive adequate face-to-face direction and professional supervision to ensure quality treatment. For focused treatment, which uses direct service providers with advanced knowledge, skills, and clinical judgment, the provider is required to establish that more experienced clinicians are required to meet the member's needs. Providers are required to indicate the amount of direct treatment delivered to the member by each provider specialty during a typical week. ForwardHealth recognizes that exceptional circumstances may occasionally result in changes to the typical treatment schedule.

If the member is a dual-language learner, the PA request must describe the team's training and accommodations to address language barriers, including the primary language that will be used during therapy activities. In addition, the provider is required to document the plan for the family to practice language learning activities outside of sessions, if the primary language used during treatment is not the parents' first spoken language. If specialized training or skills are required for team members who will be serving dual language learners, this should be documented.

Supervisor Visit

To ensure quality programming, the licensed supervisor is required to see the member often enough to confirm data and narrative progress reports provided by the team and is required to directly observe the member for at least one hour every 60 to 75 days. The one-hour minimum observation requirement every 60 to 75 days is counted from the first DOS the member received direct treatment from the provider. These visits must be documented by a detailed progress note or report and by claims submitted by the licensed supervisor for behavior assessment, behavior treatment, protocol modification, or family adaptive behavior treatment guidance. If more than 75 days elapse between supervisory visits, ForwardHealth may recoup all payments made for services delivered after day 75 until the next supervisory visit occurs.

The intent of supervisory visit is for the licensed supervisor to spend at least 60 minutes actively and solely engaged in member-focused activities, such as demonstrating protocols, coaching staff, assessing or observing member skills, or providing direct treatment. Progress notes must include descriptions of these activities in order to meet this requirement. Incidental observation of the member that may occur while the licensed supervisor provides family training and consultation to parents or caregivers does not meet this requirement.

Face-to-Face Direction

Treatment supervisors (either licensed supervisors or treatment therapists) are required to observe, demonstrate, and provide simultaneous direction of service providers during delivery of each member's treatment for a minimum of one hour and a maximum of two hours for every 10 hours of direct treatment provided, averaged over a calendar month. Providers are required to document exceptional circumstances that require direct oversight in excess of the maximum. Documentation of direct oversight of treatment delivery is required.

Professional Supervision

Consistent with Wis. Admin. Code § DHS 101.03(173), professional supervision involves intermittent face-to-face contact between supervisor and assistant and a regular review of the assistant's work by the supervisor, including general clinical guidance that may apply to multiple members. Each treatment therapist must be supervised by a licensed supervisor via weekly face-to-face or indirect contact and monthly face-to-face supervision. Each behavioral treatment technician must be supervised face-to-face by either a treatment therapist or licensed supervisor at least once a month.

Face-to-Face supervision means observing the treatment therapist or technician implementing the POC with the member and/or family present. Indirect supervisory contact includes activities such as oversight of treatment protocol, updating goals, data and progress review, crisis intervention, and family/team management; it may occur face-to-face or via phone or electronic communication, through individual or group contact. Documentation of professional supervision is required.

Note: Time spent by a supervisor observing treatment performed by a team member may fulfill the requirement for professional supervision and direct case supervision.

Comprehensive Treatment

Direct services are typically provided by behavioral treatment technicians but may be provided by behavioral treatment licensed supervisors or behavioral treatment therapists. Behavioral treatment technicians must receive face-to-face direction during delivery of direct treatment, with the member present, from either a treatment therapist or licensed supervisor. ForwardHealth requires a minimum of one hour of face-to-face direction per 10 hours of direct treatment provided by treatment technicians. If face-to-face direction exceeds two hours per 10 hours of direct treatment by treatment technicians, the provider is required to document the exceptional circumstances, such as a significant change in the member's response to treatment that resulted in a temporary need to increase direct supervision.

Focused Treatment

Direct services may be provided by focused treatment licensed supervisors, focused treatment therapists, or behavioral treatment technicians.

Focused treatment therapists must receive face-to-face direction during delivery of direct treatment, with the member present, from the licensed supervisor. ForwardHealth requires a minimum of one hour of face-to-face direction per 10 hours of direct treatment provided by the treatment therapist. If face-to-face direction exceeds two hours per 10 hours of direct treatment by treatment therapists, the provider is required to document the exceptional circumstances, such as a significant change in the member's response to treatment that resulted in a temporary need to increase face-to-face direction.

Behavioral treatment technicians must receive face-to-face case direction during delivery of direct treatment, with the member present, from either a treatment therapist or licensed supervisor. ForwardHealth requires a minimum of one hour of face-to-face direction per 10 hours of direct treatment provided by treatment technicians. If face-to-face direction exceeds two hours per 10 hours of direct treatment by treatment technicians, the provider is required to document the exceptional circumstances, such as a significant change in the member's response to treatment that resulted in a temporary need to increase face-to-face direction.

ForwardHealth covers two levels of focused behavioral treatment.

POC

The POC must indicate the intended start and end dates for the authorization period, the intended treatment hours per week, and when required, a plan to modify treatment intensity over the course of the authorization period. All dates in the authorization period must fall within the date range specified on the prescription from a physician or medical provider for treatment.

The POC must also indicate the treatment approach that will be used. ForwardHealth limits coverage to treatment modalities that are evidence-based as determined by the Wisconsin DHS. The POC must be signed and dated by the supervising provider prior to provision of care.

For members seeking comprehensive treatment for ASD, providers are required to use a curriculum of treatment goals developed for individuals with ASD, addressing skills across a range of developmental areas (for example, communication, socialization, daily living skills, learning, play skills). The curriculum must be validated in the research literature and designed to assess skills, select treatment goals, and evaluate the member's progress multiple times within a year. Examples of commonly used criterion-referenced measures for ASD include the VB-MAPP, the ABLLS, and the ESDM Curriculum Checklist.

Treatment goals must be functional and individualized for the member. They must meet the following guidelines:

• Address assessed needs of the member
• Be specific with clearly defined target behaviors
• Be observable and measurable to allow frequent objective evaluation of progress
• Include objective measures of baseline performance (for example, frequency, rate, intensity, or duration of symptoms)
• Include clear, measurable mastery criteria
• Be appropriate for the member's age and skill level

Treatment goals should be achievable within the authorization period. For complex goals that require longer than a typical authorization period for mastery, providers should complete a task analysis of the planned treatment steps and include goals based on the individual treatment steps that can be achieved within a single authorization period.

The scope of treatment goals and intensity of treatment hours should be consistent with the member's current needs. For members with prior behavior treatment, the scope and intensity of the proposed POC should be consistent with the member's demonstrated rate of skill acquisition, skill maintenance, and generalization of skills, and should be reasonably likely to result in desired gains.

Medical Conditions

The provider requesting behavioral treatment is required to obtain information regarding specific facets of the member's health that might impact the member's participation and/or expected outcomes from behavioral treatment. Details of any medical conditions that may impact treatment or response to treatment such as visual or hearing impairment, genetic difference, seizures, digestion or elimination problems, sleep disorder, nutrition concerns, or mental health concerns must be noted in the member's POC.

Members Age 18 and Older

Members who are age 18 and older must have input on treatment goals if they are able to express personal needs and priorities. If the member has formally delegated any medical decision-making to another entity, providers must submit documentation of that agreement and confirm that the decision-making entity is in agreement with the POC. If the member is able to make medical decisions independently, the member's signature on the treatment plan to confirm consent for treatment must be included.

Treatment for School-Age Members

If the member is intellectually and behaviorally capable of learning and/or socializing with same-age peers, the POC must allow regular and appropriate participation in school or other settings that support interaction with typically developing same-age peers, consistent with the member's abilities.

If the member is temporarily participating in behavioral treatment in lieu of regular school attendance, the POC must include a plan for returning to full-time attendance. The plan must include an anticipated timeline with time or skill acquisition benchmarks that will trigger each step-down in treatment hours.

If the member is participating in behavioral treatment while attending school, the POC must explain why it is medically necessary for a behavioral treatment provider to address skills typically supported by school staff. The POC must include a plan to reduce treatment in the school environment and replace with available school supports. Behavioral treatment is not intended to function as a long-term support or to supplant activities typically provided by educational staff.

Because professional educators and homeschooling parents are responsible for teaching academic content to children 6 years of age and older, ForwardHealth will not authorize POCs or reimburse behavioral treatment providers for providing educational instruction to these members.

If disruptive behaviors or deficits in prerequisite skills are impeding the member's successful participation in school, ForwardHealth may authorize and reimburse treatment that addresses these behaviors and skills. If treatment goals appear to be academic in nature but address prerequisite skills that support the member's general functioning, the goals may be evaluated for medical necessity based on the member's unique needs and the rationale given by the provider. The fact that a goal appears on a teaching curriculum and is within scope for a behavioral treatment therapist to teach does not make the goal medically necessary.

POCs for members under 6 years of age may include goals that support the development of foundation learning skills and general knowledge, such as skills that appear on school readiness checklists, provided the goals are appropriate for the member's age and assessed needs.

Including Family/Caregiver Goals

Behavioral treatment frequently seeks to make behavior more manageable for caregivers. This involves both modification of the member's behavior and enhancement of caregiver skills. For children and adult members with legal guardians, ForwardHealth expects the family and/or caregivers to be included in treatment planning and POC goals. The provider's initial assessment of the member must include reports from the family and/or caregivers about the member's current behavioral challenges and other treatment needs. The POC must include goals for the family and/or caregivers to learn how to follow protocols for managing behavior or teaching new skills. Teaching the member's family and/or caregivers about treatment protocols with or without the member present, demonstrating protocols involving the member, and coaching the family and/or caregivers in the implementation of a protocol may all be billed using the appropriate CPT codes.

Specific, measurable goals for the family and/or caregivers must be included in all POCs that include family treatment guidance as a requested service. Initial goals may focus on family participation, communication, and compliance with treatment policies and procedures. However, the purpose of family training is to help family members improve their behavior management skills and reduce the need for treatment and other supports. Goals should be individualized for the member's family or caregivers and may address a range of areas including, but not limited to:

• Increasing the accuracy and consistency of behavior plan implementation.
• Increasing the frequency and duration of successful family and community participation.
• Reducing the frequency and duration of the member's disruptive behavior outside of sessions.
• Teaching the member common adaptive skills.

Family goals must be appropriate and specific, with measurable baselines and mastery criteria.

Any PA request for continued family treatment guidance must summarize progress on family goals documented in specific, measurable, objective terms. Progress that is indicated by descriptive terms, such as "better," "improved," "calmer," "less/more," or "longer" are not measurable and will not be accepted by ForwardHealth. If the family has made limited or no progress by the end of the authorization period, a subsequent POC must clearly identify barriers to progress and propose a corrective action plan.

Including Documentation of Disruptive Behaviors

When disruptive behaviors are identified through the clinical assessment or record review for either comprehensive or focused treatment, these behaviors must be documented in the POC that is submitted as part of the PA request. As part of the behavioral assessment, the provider is required to include the following:

• A clear definition of the concerning behavior
• The baseline level (frequency, rate, duration, latency, and/or interresponse times) of the behavior and rationale for treating it immediately
• The causes or functions of the behavior (For new members, this may indicate the hypothesized function.)

Behavior reduction goals must be included in the POC, and the POC must identify skill acquisition goals that are expected to address skill deficits underlying the behavior. Mastery criteria for behavior goals should reflect behavior that is, at most, age-typical or, at least, manageable for caregivers.

When the member's disruptive behavior may be related to a co-morbid medical or mental health condition, the provider's assessment and POC must explain how the condition will be treated or otherwise addressed alongside the proposed behavioral treatment. A recent consultation to evaluate the member's medication needs may be requested.

If the problem behavior persists despite treatment, a thorough functional analysis of the problem behavior may be required for subsequent PA requests.

Discharge Criteria and Transition Plan

The POC must include the requesting treatment provider's standard discharge criteria that are refined throughout the member's treatment plan. Services should be reviewed and evaluated for discharge planning in the following situations:

• The member has achieved treatment goals.
• The member no longer meets diagnostic criteria for the condition being treated.
• The member has not demonstrated progress toward goals for successive authorization periods.
• The family wishes to discontinue services.
• The family and the provider are unable to reconcile important issues in treatment planning and delivery.
• The member is frequently unable to participate effectively in treatment (for example, due to medical issues).
• Sufficient skilled staff have been unavailable for three consecutive months, and the provider cannot guarantee that the staffing shortage will be corrected within a month.
• The member requires an intervention approach or LOC that is not offered by the provider or is not commensurate with the provider's education, training, and experience.

The POC must include discharge criteria that clearly describes a realistic range of outcomes, including lack of progress, which may result in discharge from treatment. Standard discharge criteria should be shared with members at the beginning of treatment to assist them with long-term planning.

Initial PA requests must include the provider's standard discharge criteria. Subsequent PA requests must include a transition plan that is updated based on the member's rate and magnitude of progress. Transition plans should identify the anticipated system(s) of care (for example, school, personal care) that will support the member following the current course of behavioral treatment; the plans should include an anticipated timeline with time or skill acquisition benchmarks that will result in a progressive transition to the next system of care.

Information regarding documentation requirements for a PA request and retroactive enrollment is available.

Care Collaboration

Collaboration with other professionals helps ensure member progress by ensuring consistency of care. Treatment goals are most likely to be achieved when there is shared understanding and collaboration among all health care providers serving a member. In addition, requested services may not duplicate services delivered by other providers.

Every PA request must identify the individual on the member's team who directs communication and collaboration with other care providers serving the member.

The PA request must document efforts to collaborate with other service providers who may be working to achieve the same or similar goals. Planned communication may include, but is not limited to, record review, sharing the POC, phone or email check-ins, attendance at team meetings, or observation during therapy sessions. Providers are required to retain documentation of collaborative activities, which may include phone logs, summaries of conversations or written communication, copies of the POC, staffing reports, or received written reports.

Supporting Documentation

Additional documentation identified on the PA/BTA form may be required, depending on the specific PA request. When these documents are required, they must meet the following standards.

Prescription From a Physician or Medical Provider

Any qualified medical provider can write the prescription for behavioral treatment. The qualified medical provider must be enrolled with Wisconsin Medicaid. The prescription for behavioral treatment services, from a physician or medical provider authorized to prescribe, must include the following:

• The date of the prescription
• The name and address of the member
• The member's ForwardHealth ID number
• The service to be provided
• The amount of service to be provided and the estimated length of time required (for example, ____ hours/week x ____ months)
• The name and address of the prescriber
• The prescriber's NPI
• The prescriber's signature

A prescription from a physician or medical provider must include the number of hours of services per week being prescribed. Medically necessary behavioral treatment services are covered as prescribed but do allow for variances not exceeding a total of 45 treatment hours per week. ForwardHealth allows flexible use of approved behavioral treatment services within these parameters to accommodate situations that would necessitate variances, such as inclement weather and illness of the member. If more hours are billed than what was prescribed and approved through the PA process, the provider's documentation must reflect the circumstances that indicate a need for additional time. Claims may be recouped for excessive billing with inadequate documentation.

Proposed Schedule of Treatment Hours and School Hours.

The schedule of treatment hours and school hours must be a proposed, grid-style weekly schedule for the member indicating the specific blocks of time when the member will be in school and in treatment. Providers are advised to submit alternate proposed schedules if a change in the member's schedule is anticipated within the authorization period (for example, school year versus summer schedule). If the child is being homeschooled, this should indicate the blocks of time that the family intends to provide required educational programming each day. It should also include any regularly scheduled commitments, such as day care, outside therapies, or supportive services.

Most Recent School IEP

The most recent school IEP must include current intervention goals and a list of services that will be delivered during the requested authorization period.