FREQUENTLY ASKED QUESTIONS

A-The consumer or legally responsible party should call Pathways Access Line at 1-800-898-5898. During this call questions will be asked about the consumer’s needs and current situation. For agency referrals (i.e., DSS, physician, school) the person making the referral can call the Access Line with the consumer present and explain the reason for the referral, but the consumer or legally responsible person will still need to provide information directly to the Access Line staff. Based on the information provided, a recommendation will be made about what service the consumer needs. The Access Line staff will tell the consumer who in the consumer’s community can provide that service and the consumer will be able to choose a provider from that list. The chosen provider will be considered the “clinical home provider” or the care coordinator who works with the consumer to schedule and facilitate the treatment team process, schedule a diagnostic assessment, take the lead in developing the person-centered plan and provide 24/7 crisis assistance.

A -In cases involving court involved consumers, an initial intake should be provided to determine whether or not a referral for services is necessary. There are several providers willing to provide these assessments for court-involved consumers. Once the need for enhanced benefits is determined and the courts/DSS orders the consumer to follow through with recommendations, the consumer would be referred to choose a “clinical home provider” (usually a community support worker or targeted case manager) who is responsible for scheduling the more thorough diagnostic assessment, facilitating the treatment team process and reporting back to the court as requested. This consumer choice process for the clinical home provider can be done by the assessment provider, by Pathways Access Line (1-800-898-5898) or if the child has Medicaid, by direct referral to an appropriate provider. If the consumer needs basic benefits only and has Medicaid the consumer can be referred directly to an outpatient services provider. For other funding sources, Pathways Access Line can assist the consumer in finding out which providers are available to assist them.

A- Medical Necessity means that in addition to being beneficial, the services a consumer receives must also be known to be effective; consistent with the diagnosis, needs and consumer’s plan of care; be delivered in the least restrictive environment; and based on state service definitions. Services must also be designed to prevent or reduce life threatening conditions, reduce symptoms that impair the consumer’s quality of life, or teach skills or provide supports to enhance the consumer’s independent living and quality of life. For Medicaid-funded services, Value Options determines medical necessity. For state-funded services, Pathways makes authorization decisions.

A- Value Options is a private business with which the state of NC has contracted to provide authorization review for Medicaid-funded and CAP services. As of September 1st, all authorization requests for all Medicaid-funded services for Children and Adults, in all three disabilities, must be sent to Value Options. The only requests that should be sent to Pathways are: IPRS requests (for all three disabilities) and VO attestation requests for providers that are authorized by VO but still bill through Pathways. The attestation request states that a proper authorization request has been submitted to VO (whether approved yet or not).

A-For Medicaid-funded consumers, they will be submitted to Value Options with the authorization requests and to Pathways for our review. For consumers who receive state-funded (IPRS) services, the Person-Centered Plan should be submitted to Pathways on-line in BUI/CMHC. It is recommended that all providers use the BUI/CMHC Person-Centered Plan.

A – During the initial call, once a treatment need is identified, the Access Line staff will identify the available providers based on the service needed and the consumer’s location, funding, and specific needs. Any information available about the providers will be given to the consumer, who will then choose a provider. If an appointment cannot be scheduled at the time of the call, the provider is notified of the referral and has 72 hours to call the consumer and schedule a first appointment or inform the Access Line of the inability to make contact. This provider is considered the “clinical home” provider with responsibility for scheduling a diagnostic assessment within 30 days (again with a provider of the consumer’s choice) and working with the consumer to pull together a treatment team, developing the person-centered plan, and providing 24/7 crisis assistance. Through the treatment team process, other needs may be identified and this provider will also assist the consumer with the choice process for each identified service. At any time during the treatment process, the consumer has the right to change providers for any reason. If the consumer is not comfortable telling their provider they want to change, the consumer can call Pathways Access Line at 1-800-898-5898 and request help with the choice process.

A – Pathways employs four Provider Specialists who are each assigned to monitor Providers. The Specialists are responsible for conducting conditional and full endorsement reviews and monitoring of providers in our community at least annually. These monitorings are to ensure quality of care, compliance with staffing and service requirements. The Provider Specialists also monitor their assigned providers “for cause” as needed (for example, when a specific concern or complaint is lodged against the provider). Pathways is developing a Provider Performance Report that will provide information about the status of endorsement and the status/results of recent monitorings and/or plans of correction.

A-Any of your current providers should be able to assist you in the consumer choice process. Your clinical home provider, in particular, should be working with you through the treatment team process to determine what services you’ll need and should help you make an informed choice about who provides those services. Consumers who are not comfortable having their provider assist them can call the Pathways Access Line toll-free (1-800-898-5898) and request help with the consumer choice process.

A- The state has said that they will not be producing a state-wide Diagnostic Assessment format. Pathways has developed a recommended format that can be used on BUI/CMHC for the Diagnostic Assessment. However, providers are not required to use that format. For Person-Centered Planning, the state has developed a statewide Person-Centered Plan available on BUI/CMHC system. If a consumer receives a state-funded (IPRS) service, the Diagnostic Assessment and Person-Centered Plan must be entered on-line in BUI/CMHC.

A- All providers of Medicaid-funded services will go through a process called endorsement – to show the provider has met certain qualifications and is “endorsed” to provide a specific service. If a provider is not endorsed for the service, then Medicaid and the state will not pay for the service. This endorsement process was designed by the state but is conducted and monitored locally by Pathways Provider Specialists. Currently, all endorsed providers are considered “conditionally endorsed”. This means they have the policies and procedures in place that are required to provide the service for which they are being endorsed. Within a year from the date of conditional endorsement, providers must become fully endorsed, which means they have demonstrated the ability to provide the services and comply with the service definitions. Endorsement is not required for providers of Developmental Therapy and any other service that is funded only by the state. However, these providers still need to complete the compliance verification process conducted at the local level and will need to meet Pathways contract requirements.

A- They may be able to provide services that are only funded by IPRS (state) funds; for example, Developmental Therapy and Supported Employment. While providers aren’t required to be “endorsed” for these services, they still complete a compliance verification process.

A- In March 2006 changes were made by the state and the federal government in the mental health, substance abuse and developmental disability services that can be paid for by Medicaid or state funding (IPRS funds). Along with these changes services were divided into “basic services” (outpatient therapy and/or psychiatric/medication services only) and “enhanced services” which include the more intensive treatment services. While some services, like Community Based Services (CBS) or Mental Health Case Management were eliminated in 2006, others, like Intensive In-Home services, Community Support Services, and Developmental Therapy were added. The list of new services and an overview of the changes can be found on the DMH Website Link on the Pathways website.

A- After March, 2006, consumers with mental health and substance abuse issues will no longer have a “Case Manager.” Instead they may have a Community Support provider. Consumers with developmental disabilities will continue to have a Case Manager. However, each consumer with enhanced service needs will be able to choose a clinical home provider to coordinate their care. This includes pulling together the treatment team, reviewing service options, developing the person-centered plan and providing 24/7 crisis assistance. This clinical home provider will most often be a Community Support Service provider or a Targeted Case Management provider.

A- IPRS stands for Integrated Payment & Reimbursement System. It refers to the use of state dollars (North Carolina) to pay for services. State IPRS funds are used to pay for services for consumers who are not eligible for other funding sources (i.e., Medicaid, Health Choice, Medicare, Private Insurance) or to pay for services that are not covered by these other funding sources (i.e., vocational programs). The state determines the amount of money Pathways and other LME’s get and the state divides the funding into separate “pots” earmarked for certain consumers (adult mental health, adult substance abuse, adult developmental disability, etc.). These funds are not entitlements and are managed locally by Pathways. Most IPRS services include some payment by the consumer. Discounted fees are available on based on income and family size.

4. Q–What is the “Closed Network”?

A – Because the state controls how much funding is available to us and because the demand for services is always greater than the funding available, Pathways made the decision to have a “closed network” of providers for all IPRS-funded services. This will allow Pathways to ensure that IPRS dollars are spent in the most effective and cost-efficient manner. The closed network still includes multiple providers for most services. In some cases, however, there is only 1 provider for very specialized and/or facility-based services. These closed network providers have agreed to provide services for consumers referred to them and in return Pathways provides a pre-determined amount of funding on a monthly basis.

A- Yes and no. In most cases, as new consumers enter the system, they will have a Diagnostic Assessment within the first 30 days rather than the previous intake evaluation. The Diagnoistic Assessment is a more thorough and comprehensive evaluation that includes face-to-face interaction with and sign off by a licensed clinical professional and a psychiatrist, nurse practitioner, physician assistant, or Ph.D. psychologist. However, each provider will probably continue to have a program intake or program assessment they complete on consumers who enter their service to ensure they are appropriately placed.

A-Consumers who only receive Basic Benefits (therapy and medication services) are not necessarily required to have a Diagnostic Assessment. Through the treatment and authorization process, it may be determined that the consumer needs a Diagnostic Assessment. Consumers who only receive Basic Benefits will need to have a version of the treatment plan, but they do not have to have the full version of the statewide Person-Centered Plan.

A- CAP-MR/DD stands for Community Alternatives Program for Mentally Retarded/Developmentally Disabled consumers. It is a program designed to keep consumers in the community who otherwise would be at risk of institutionalization. Consumers who meet this level of care must be Medicaid eligible and have an MR2 form completed by a physician. The state Division of MH/DD/SA makes the final determination of who is included in the CAP-MR/DD program. CAP-MR/DD consumers can receive day-time, residential support services, specialized equipment, respite, etc... CAP services cannot be provided in the school setting and CAP consumers cannot receive Developmental Therapy services (which are similar to the services that used to be called CBS – Community Based Services). Individual consumer situations should be discussed in the treatment team so that specific options can be examined.

A-If the consumer is receiving a service that is not meeting his needs and his functioning begins to deteriorate, a higher level of care may be necessary. Likewise, if the consumer is improving significantly, it may be appropriate to begin reducing use of the current service or to move to a less restrictive or less intensive level of care. The treatment team should get back together any time there is significant change or no improvement over time in order to re-assess the consumer’s needs and goals and develop a new plan of care.

A-This information can be found in each of the service definitions available on the state’s website
( http://www.dhhs.state.nc.us/mhddsas   ).

A-There is still a “firewall” for consumers who receive Developmental Disabilities services. Therefore, a consumer cannot receive Targeted Case Management and any other service from the same provider. A consumer who receives Targeted Case Management would have to choose another provider (or providers) for all their other services. Additionally, Targeted Case Management and Community Support cannot be provided at the same time, since both have care coordination responsibilities. A consumer who moves from Targeted Case Management to Community support could choose to keep the same provider, if consumer choice process is followed and if the provider is appropriately endorsed for that service.

A-If the direct service staff’s training and experience allows them to serve multiple populations, we are not aware of anything that would disallow this. So, yes a provider could have a mixed caseload (age and/or disability). However, some services have specific case-load limits that would still need to be adhered to.

A-Consumers should work with their treatment team for assistance in finding a primary care physician. This is part of the provider’s responsibility under care coordination. In some cases, the Health Department may be a resource to help in accessing primary care.

A-Pathways is not adding any new IPRS closed network providers at this time. If funding allows in the future we will do so. Providers may express a formal interest in this by emailing Gayle Mahl at Pathways at gmahl@pathmhddsa.org

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