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BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association.
Bruce Davis, Ph.D, TN Dept. of Intellectual and Developmental Disabilities
Melissa Isbell, Mgr. Provider Relations, BlueCare Tennessee
Delivering Applied Behavior Analysis Services to the TennCare Population
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Panelists
Patti van Eys, Ph.D
BlueCare Tennessee
Katherine Wooten, LCSW
BlueCare Tennessee
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Learning Objectives:
Understand how delivery of services is the same for DIDD and BlueCare/TennCare Select
Understand how delivery of services is different under DIDD and BlueCare/TennCare Select
Documentation Requirements
Upcoming Changes
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Your Contracts for ABA Services – Common Threads
Compliance
Disclosure
Availability of Records
Documentation
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Essential Assessment Components
Demographics and Date of Assessment
Reason for Referral
Description of Behaviors of Concern in Observable and Measurable Terms
Hypotheses Regarding Medical, Psychiatric, and Other Contributions (i.e., ecological) to Problem Behavior (Motivating Operations)
Hypotheses Regarding Functions of Target Behaviors Based on Direct Observations
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Essential Assessment Components, continued
Baseline Data for Target Behaviors
Functional Analysis Summary w/graphs
Identification of Functionally Equivalent Replacement Behaviors/Contingency Management
Objectives for Target and Replacement Behaviors
Service and Behavioral Recommendations
Risks/benefits/possible side effects/ potential contraindications for recommended approach
Signature
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Graphing Progress
Steps:
Appropriately Labeled Horizontal (x) and Vertical (y) Axes
Labeling Graph Title and Caption
Labeling Axes
Legend
Phase Change and Event Lines
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Behavioral Support Plan
List of Target Behaviors: frequency, intensity, duration
Identify Prevention Strategies
Reinforcement Strategies – Identify Conditions Under Which Reinforcement is Provided
Teaching Strategies for Replacement Behavior/ Contingency Management
Responses to Targeted Problem Behaviors
DIDD Behavior Services Work Product
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Follow Up Documentation
Records should include:
Date of Service
Client Info on Each Page (DOB, etc.)
Behavioral Change Objectives/Corresponding Assessment of Progress
Appropriate Objectives (observable, measurable, time limited)
Adverse Incidents
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Follow Up Documentation, continued
Stated Hypotheses Regarding Function of Behaviors of Concern Based on Most Recent Data Collected
Reliability of Data Collected and Implementation Reliability for Planned Interventions
Assessment of Effectiveness of Plan (ideally every time, but at least quarterly)
Assessment of Continued Appropriateness of Selected Replacement Behaviors/Contingency mgt.
Documentation of Training Provided to Caregivers
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Follow Up Documentation, continued
Adjustments or revisions to behavioral objectives: If objectives are met, advance to a subsequent objective or discontinue service. If not met, consider modification to make them more achievable.
Recommendations for Any Adjustments to the Plan
Recommendations to Continue at Current Level or Increase/Decrease/Discharge
Signature and Date
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Tips
Contact notes can be brief summaries that can be expanded upon in service reports
Formally analyze activities
Document extraneous events that impact outcomes (event lines in graphs)
Document Factors Outside Control (barriers)
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Tips, continued
Document where the services took place (home, school, community, etc.)
Document types of interventions (training, modeling, revising plan, etc.)
What was the level of caregiver involvement?
Note any significant life changes (new school, new home, new medication)
Specify the severity of the behavior (describe words such as “aggressive”)
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Tips, continued
Document how the caregivers are doing with the member when you are not there. Good day or bad days? Significant interventions such as crisis team or ER visit? Remember to report those Adverse Incidents!
Identify any additional services the member or family might need in addition to ABA – we can help facilitate!
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Monthly/Quarterly Reviews (see Documentation Section)
Assessment of Objectives
Reliability of Data and Implementation
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Medical Necessity Reviews
BlueCare/Select
initial review process
concurrent review process
“Tips” document from UM for case examples
DIDD
Imminent risk of harm
Significant damage to property
Impairs community living
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Common Issues Noted During Medical Necessity Reviews
Inconsistency of Information Provided
No Demonstrated Benefit in the Documentation
Services Not Justified
Documentation is not Thorough Enough to Mitigate Liability in the Event of an Incident
No Solid Clinical Summary
Curriculum is not Individualized
Failure to fully document caregiver training and caregiver progress/lack of progress regarding BSP
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Audit Elements (in addition to Documentation)
Number of encounters scheduled v. Number of Encounters completed
Number of units approved v. number of units used/expired/unused
Signature, credentials, date completed
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Medical Necessity Criteria
BlueCare and DIDD use the same MNC, found below at:
http://www.tn.gov/tenncare/forms/apcard.pdf
DIDD and BlueCare Credentialing Criteria are different
Heed distinctions in Quick Guide regarding MNC v. educational needs (website link on slide 22)
DIDD Protocol
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Non-Billable Activities
Services Not Within the Scope of Behavior Analyst
Must Be F2F or collateral F2F Except for Assessment and Plan Development Phase
Documentation Following Direct Services (i.e., contact notes)
Travel Time
Services Rendered by Someone Other Than Contracted Behavior Analyst (unless an identified alternate)
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Non-Billable Activities, continued
Services or Reporting Rendered at the Pleasure of the Court or LEA (unless also determined Medically Necessary
Services Defined in the Interagency Agreement between TennCare and Education as being covered as part of an IEP or FAPE
For DIDD only, Services must be F2F with person or staff training (yearly limit applies to training)
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Modalities
Group Services – No billable ABA services in TN
Telemedicine – expressly prohibited by TennCare policy
TennCare specific exclusions available at:
http://www.tn.gov/tenncare/forms/quickguide.pdf
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Updates on Insurance, Licensure and Credentialing
Insurance coverage will not change this year in TN
Summer legislative study session on proposed licensure for ABAs
Potential changes for credentialing requirements in TN contingent upon licensure and legislative changes
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Additional Resources
Your Provider Agreements
Provider Manuals (incorporated by reference in your Provider Agreements)
TennCare website
BlueCare/TennCare Select Regional Network Managers
DIDD Protocol
Interagency Agreement located at
http://www.tennessee.gov/education/speced/doc/ideainteragency_000.pdf
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On The Horizon
DIDD Provider Manual Changes
BlueCare/TennCare Select Coding Addition
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Questions?
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Thank You!