Utilization Review Process

PURPOSE: This rule formally establishes a statewide utilization review process to: ensure individuals eligible for division services with similar needs are treated consistently and fairly throughout the state; ensure each individual’s annual plan accurately reflects the individual’s needs; ensure levels of service are defined and documented within the outcomes of each individual’s plan; prioritize need for services; and ensure accountability of public funds. (1) Definitions. (A) Authorization—Approval notice to a provider that a specific amount of service at a specific rate may be provided to an individual. (B) Budget—The total cost of services and supports funded through the division recommended or approved to meet an individual’s needs identified in an Individualized Support Plan. Services and supports paid for outside of the department billing system are excluded from the budget. (C) Department—Department of Mental Health. (D) Division—Division of Developmental Disabilities. (E) Emergency criteria consist of one (1) or more of the following: 1. The individual is in immediate need of life-sustaining services (food and shelter, or protection from harm) and there is no alternative to division funding or provision of those services; 2. The individual needs immediate services in order to protect self or another person from imminent physical harm; 3. The individual is residing in an intermediate care facility for persons who have developmental disabilities (ICF/ DD) or a skilled nursing facility (SNF) and has been assessed as able to live in a less restrictive arrangement in the community, the individual wants to live in the community, and appropriate services and supports can be arranged through the waiver; 4. The individual had been receiving significant services through division waiver-funded programs and services, is evaluated to still need the significant level of services, but is no longer eligible for the program or services due to age; or 5. The individual is in the care and custody of the Department of Social Services, Children’s Division, which has a formal agreement in place with the division to fund the costs of waiver services for the specific individual or for individuals who are in a Voluntary Placement Agreement (VPA). (F) Missouri Adaptive Ability Scale (MAAS)—A normreferenced, standardized assessment of functional ability. The MAAS shall be used to determine number and severity of functional limitations for eligibility, prioritization of need score, and rate setting. (G) Person-centered planning process—A process directed by the individual, with assistance as needed from a guardian, public administrator, the responsible party, or other person as freely chosen by the individual. The process may include other individuals freely chosen by the participant who are able to serve as important contributors to the process. The personcentered planning process enables and assists the individual to access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes and the training, supports, therapies, treatments, and/or other services become part of the ISP. (H) Prioritization of need (PON) score— A component of the MAAS that quantifies the level of impairment of an individual and is used to determine priority of access to services. The PON score is expressed on a one (1) to five (5) scale with five (5) being the highest possible score. (I) Responsible party—The parent(s) of a minor child, spouse, court appointed guardian, public administrator, or any other person who has legal authority to make decisions for a person served by the division. (J) Senate Bill 40 County Developmental Disability Boards (SB40 Board)—County boards established pursuant to section 205.970, RSMo, to provide services with voter approved tax levies to residents of that county who are handicapped persons as defined in sections 178.900 and 205.968, RSMo. (K) Individualized Support Plan (ISP)—A document directed by the individual, with assistance as needed from a representative, in collaboration with a planning team. The ISP identifies strengths, capacities, preferences, needs, and desired outcomes of the individual. The ISP shall encompass personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes. Training, supports, therapies, treatments, and/or other services to be provided for the individual become part of the ISP. (L) Service/Support—Informal and formal means of meeting needs identified in the ISP. (M) Utilization Review (UR)—A formal process at the regional office to review PON, proposed ISPs, and budgets and make recommendations for approval, modification, or denial of the requested services. The regional director or assistant regional director has the authority to review and approve recommended services and may designate individuals to review and approve recommended services. The authority to deny or modify requested services lies solely with the regional director or assistant regional director. (2) Following the establishment of eligibility for division services in accordance with 9 CSR 45-2.010, the personcentered planning process begins. An ISP is developed through discussion with the individual and/or guardian and with input from others as directed by the individual and/or guardian. The ISP, budget, and PON (if applicable), are then submitted to UR, and a copy of the ISP, budget, and PON (if applicable), is provided to the individual and/or guardian. (A) A PON score is necessary when there is a request to begin participation in any waiver. (B) A new assessment of PON shall be completed when an individual on a waiting list experiences a change in personal circumstances, environment, or family situation impacting level of need. (C) UR is necessary under the following circumstances: 1. When individuals will be receiving funded services for the first time; 2. When the individual’s ISP and budget is amended by adding new services or increasing the dollar amount of a specific service; 3. When individuals who are participating in the Partnership for Hope waiver move from a participating county into one that does not participate in the Partnership for Hope waiver; or 4. Any other situation at the discretion of the regional director. (D) UR is not necessary when there is no change to the ISP or budget, but the ISP may be reviewed at the discretion of the regional director. (E) In emergency situations as described in paragraphs (1) (E)1.-5. of this rule, the regional director has the authority to approve an increase in a ISP to protect the health and safety of an individual and to subsequently report the decision to the support coordinator who will develop an ISP amendment. (3) Following implementation of the initial ISP and annually thereafter, two (2) months prior to the proposed ISP and budget implementation, the service coordinator shall meet with the individual, the individual’s family, and as appropriate the individual’s responsible party to prepare an ISP and budget with justification for the individual’s support needs. (A) The ISP and budget shall be agreed to and the ISP shall be signed by the individual and/or responsible party. (4) One (1) month prior to the proposed ISP and budget implementation, the service coordinator shall submit the signed ISP to the regional director or the regional director’s designee for approval. Plans submitted that include services with a start date less than thirty (30) days from the implementation date shall not expedite approval timelines. (A) If the ISP and budget submission to UR shall otherwise be delayed due to the inability of the service coordinator to obtain the signature of the individual or responsible party, then the ISP and budget shall be forwarded to UR without the signature and a copy of the ISP and budget shall be mailed to the individual or responsible party. (5) UR shall recommend for approval a service/support for inclusion on a prioritized waiting list if the service/support meets each of the following criteria: (A) Need for the service/support is documented in the ISP as necessary for the individual’s health, safety, and/or independence and alternative funding or programs are not available to meet the need; (B) Need for the service/support is specifically related to the person’s disability (i.e., not something that would be needed regardless of the person’s disability); and (C) Individuals evaluated with needs meeting emergency criteria receive highest priority in receiving funding for services. (6) The division shall maintain a waitlist for entry into the Division of Developmental Disabilities waiver- funded services. The regional office enters individuals on a prioritized waiting list when services requested in an approved ISP require entry into a waiver. Individuals evaluated with needs meeting emergency criteria receive highest priority in receiving funding for services. (7) UR shall review the ISP, budget and PON (when required) within six (6) business days of receipt. A PON score based on the emergency criteria will be reviewed by the regional director or their designee for verification. (A) If sufficient information is submitted, the regional director or the designee may approve the ISP and budget. The regional director or designee has five (5) business days to render a decision. (B) If more information is needed or changes are necessary in the budget or service authorization associated with a ISP, that information shall be requested from the service coordinator, who has ten (10) business days to respond. Upon receipt of the requested information or following the conclusion of these ten (10) business days, the regional director or designee will then have five (5) business days to render a decision. (8) Following the decision by the regional director or designee, a decision letter and the completed ISP and budget shall be provided within ten (10) business days of the decision to the individual and/or responsible party, service coordinator, and provider(s). If the regional director disapproves or modifies an ISP and budget, the regional director shall include in the decision letter the reason(s) for the disapproval or modification and must provide information on rights to appeal. (9) The individual or responsible party may appeal the decision, in writing or verbally, to the regional director or assistant regional director within thirty (30) calendar days from the date of the decision letter. (A) If necessary, appropriate staff shall assist the individual or responsible party in making the appeal. (B) The regional director or designee may meet with the individual or responsible party and any staff to consider any information relevant to the final decision and to hear any comments or objections related to the decision. (C) Within ten (10) business days after receiving the appeal, the regional director or designee shall notify the individual or responsible party in writing of the decision. (10) When the decision, as set forth in section (8) above, results in any individual being denied service(s) based on a determination the individual is not eligible for the service(s) or adversely affects a waiver service for an individual, the individual and/or responsible party may appeal in accordance with the procedures set forth in 9 CSR 45-2.020(3)(C). (A) An individual and/or responsible party participating in a Division MO HealthNet/Medicaid waiver program has appeal rights through both the Department of Mental Health and the Department of Social Services. Those individuals may appeal to Department of Social Services before, during, or after exhausting the Department of Mental Health appeal process. Once the appeal process through Department of Social Services begins, appeal rights through the Department of Mental Health cease. Individuals appealing to the Department of Social Services must do so in writing within ninety (90) calendar days of written notice of the adverse action to request an appeal hearing. Requests for appeal to the Department of Social Services should be sent to MO HealthNet Division, Constituent Services Unit, PO Box 6500, Jefferson City, MO 65102-6500, or call Constituent Services Unit at 1 (800) 392-2161. (11) If an individual and/or responsible party timely files an appeal of a decision, services currently being provided under an existing ISP will not be suspended, reduced, or terminated pending a hearing decision unless the individual or legal representative requests in writing that services be suspended, reduced, or terminated. (A) The individual and/or responsible party may be responsible for repayment of any federal or state funds expended for services while the appeal is pending if the hearing decision upholds the director’s decision. (12) The service coordinator shall provide guidance to the individual, family, and the responsible party about any alternative resources potentially available to support needs that are not approved through the UR process. (13) New services/supports that result in an increase in the total budget shall not begin before the ISP and budget are approved through the UR process and approved by the regional director or designee, except in an emergency situation approved by the regional director or designee. Services approved due to an emergency situation may not exceed sixty (60) calendar days. An extension of up to an additional sixty (60) calendar days may be requested in writing and may be approved in writing at the discretion of the regional office director. (14) Budgets are determined by the total cost of all services and supports paid through the billing system of the department. Services and supports paid for outside of the department billing system are excluded. (A) When multiple family members are receiving division services, this shall be noted. All of the budgets shall be considered together in the utilization review process in order to have a comprehensive picture of all services/supports going into a single home so the necessary level of services can be determined. This does not require each family member’s ISP be on the same plan year, but does require all of the current supports in the home be considered. (B) Applicable Medicaid State Plan services shall be accessed first when the individual is MO HealthNet-eligible and the services will meet the individual’s needs. (15) A review, modification in units, or denial of a service should not delay the implementation of other services in the plan. (16) Other ISP and budget reviews shall continue to be completed by the service coordinator and/or service coordination supervisor, as directed by the regional director. AUTHORITY: sections 630.050 and 633.110.2., RSMo 2016.* Original rule filed March 31, 2006, effective Nov. 30, 2006. Amended: Filed Feb. 1, 2012, effective Sept. 30, 2012. Amended: Filed Sept. 27, 2022, effective April 30, 2023.** *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 633.110, RSMo 1980, amended 2011. **Pursuant to Executive Order 21-09, 9 CSR 45-2.017, paragraph (3)(B)2. was suspended from April 23, 2020 through December 31, 2021.