Utilization Review

Purpose

The purpose of a Utilization Review (UR) is to ensure that a child’s current needs are accurately reflected in the assigned level of care (LOC) and to periodically review a child’s progress in care. For children in a Private Child Caring (PCC) residential placement or a Private Child Placing (PCP) therapeutic foster care placement, it is the provider's responsibility to send in the necessary documentation for the LOC assignment.


Protocol

In order for CRP to complete a Utilization Review, the PCC/PCP must submit to CRP an Application for Level of Care Payment (ALP/CRP-7) and a Child and Adolescent Needs and Strengths Assessment (CANS) report completed during the UR reporting period.

  • When a CANS report is not available, ONE of the supplemental tools on the list below may be submitted. The supplemental tool submitted must include child-related information from the current reporting period and provide information relevant to assigning a level of care.
     
    • Assessment/Biopsychosocial
    • Discharge information from previous placement (must include information about child’s progress and service needs)

    • DJJ/Court information

    • DPP-1294B

    • IEP/Educational information

    • Medically complex information (including Individual Health Plan)

    • Psychological evaluation

    • Psychiatric hospital/PRTF information (e.g., discharge summary, treatment considerations)

    • Treatment Plan (must include information about the child’s progress on treatment goals)

       

  • Youth who are 18 years or older do not require a CANS or supplemental tool when submitting documentation for a level of care assignment.
  • For children placed in a new program within 30 days of the UR being due, programs have the following options for submission:

    Option 1: Programs may complete the 1st page of the ALP and attach an initial assessment completed by the program.

    Option 2: Programs may complete the 1st page of the ALP and attach an 886A (not more than 30 days old) and the CANS OR other approved supplemental tool listed above.

    Option 3: Programs may complete the ALP in full and attach the CANS OR other approved supplemental tool listed above.

 


Schedule

  • For a PCC, the ALP is due every 3 months.
    • Information provided in the ALP should be based on the child’s behaviors and needs in the 3 months prior to the UR due date.

    • A level is not assigned with the first ALP submission (after 3 months in placement). The first level will be assigned after 6 months in placement and every 3 months thereafter.
     

  • For a PCP, the ALP is due every 6 months.
    • Information provided in the ALP should be based on the child’s behaviors and needs in the 6 months prior to the UR due date.

    • A level will be assigned every 6 months.
     

  • For an Independent Living Program, the ALP is due every 6 months.
    • Information provided should be based on the child’s behaviors and needs in the 6 months prior to the UR due date.

    • A level will be assigned every 6 months.
     

  • The program in which a child is placed at the time of the UR due date is responsible for submitting the ALP (CRP-7) and CANS/other approved supplemental tool.

  • According to 922 KAR 1:360 the PCC/PCP must submit required reports for the UR in time for the reports to be received by CRP within thirty (30) days prior to or on the UR due date. Because there is a 30-day window in which reports can be submitted, exceptions are not made for late reports.

  • A program submitting materials for a UR may wish to call after 24 business hours if the Youth Information page of CRP’s web application does not show the materials as being received.

  • All children who are 4 years of age or older in a level of care placement require a level assignment. Therefore, about 30 days prior to a child’s 4th birthday it is important that the program remind the child’s DCBS Worker that the child requires an initial level of care. The DCBS Worker will need to submit a packet (886A and SAFESPACE Screener OR other approved supplemental tool). A PCC/PCP may help expedite the level of care assignment process by providing a CANS report or one of the supplemental tools to the DCBS Worker to submit with the level of care packet.
  • Regardless of whether the DCBS Worker has submitted the materials required for a 4-year-old child to be assigned a level of care, it is still the program’s responsibility to submit materials for a UR, based on the intervals established for their program. Please contact CRP with any questions regarding this issue.

  • Upon completion of a UR, the Notice of Level of Care Payment Authorization (CRP-2) will be submitted by CRP to the DCBS Billing Clerk and the PCC/PCP.

  • For PCC/PCP funding, the effective dates for LOCs that have been changed as a result of a UR vary according to 922 KAR 1:360 and are summarized in PCC Payment Dates.


SUBMITTING MATERIALS

Submit all materials to the Children’s Review Program. Materials can be:

  • Securely emailed to [email protected];

  • Faxed to 859.225.3565; or

  • Mailed to Children’s Review Program, 1351 Newtown Pike, Building #3, Lexington, KY 40511


On-Line Training for Completing the Application for LOC Payment (ALP) (CRP-7)

A 1.25 credit hour on-line training for how to complete an Application for Level of Care Payment (ALP) form is now available through Eastern Kentucky University’s TRIS Web-based Training site.