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LMHAs and SB58 Providers: Quarterly Retrospective Review Process

Date: 03/22/21

Superior HealthPlan conducts quarterly retrospective reviews for Local Mental Health Authorities (LMHAs) and multi-specialty groups (SB58 providers) who service Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members. This review process is conducted to ensure that services are provided in accordance with Uniform Managed Care Manual (UMCM) Chapter 15, including ensuring providers meet all training requirements and the use of the Department of State Health Services (DSHS) Resilience and Recovery Utilization Management Guidelines (RRUMG).

Annually, LMHAs and SB58 providers must submit an annual attestation via email to ProviderCertifications@SuperiorHealthPlan.com that outlines specific elements a provider must meet. Please be advised if any of these elements are not accurate according to the attestation submitted, it will be considered a compliance issue and potential cause for recoupment. To access the attestation and review required elements, please download the SH58 Attestation Form in the Credentialing section of Superior’s Forms webpage.

Based on recent reviews, Superior is providing additional clarification on the retrospective review process. Please review the details, as well as updates to the process, below.

Updates to Documentation Required

Upon request from Superior’s Utilization Management department, LMHAs and SB58 providers must submit Adult Needs and Strengths Assessment (ANSA) and Child and Adolescent Needs and Strengths (CANS) assessments for services within the date span requested of the review. These assessments must be printed directly from the Clinical Management for Behavioral Health Services (CMBHS) web-based system. Assessments must be in Active, Closed or Complete status with each chart request; Draft status assessments will not be accepted.

Other important notes:

  • Providers must not deliver services to members without an Active CANS/ANSA in the CMBHS system.
  • Only one LMHA or SB58 provider is allowed to have an Active assessment in CMBHS and provide services to a member at one time.
  • If a member changes their LMHA or SB58 provider, their previous provider will need to discharge the assessment so the new provider can begin an assessment in CMBHS system.

For assistance with the CMBHS system, providers can call the Texas Health and Human Services (HHS) CMBHS Help Line at 1-866-806-7806. For additional information, please visit the CMBHS webpage.

Documentation Due Date

Providers will receive the due date for requested documentation (recovery plans, assessments, etc.) via an email from their assigned Superior Utilization Manager, with at least 1 week notice. Providers can anticipate that the documentation will be due at least 1-2 weeks in advance of their scheduled feedback meeting. Any documentation must be submitted within 2 business days of the feedback meeting to ensure compliance. Documentation received after the due date will not be considered for their review score, but may alleviate issues with compliance. Superior Utilization Managers can note receipt of additional documentation on the feedback form, however, re-scoring the review will not occur.

Identification and Recovery of Identified Overpayments

As part of the review, any paid claims that are not supported by the documentation submitted are subject to recovery. Examples of possible claim overpayment and recoveries include, but are not limited to:

  • Missing documentation for services billed.
  • Billing two services concurrently (overlapping services billed).
  • Billing for transportation.
  • Billing without an active CANS/ANSA or recovery plan on file.
  • Billing without the person providing the service having an active CANS/ANSA certification.
  • Billing for an incorrect service (i.e. skills training billed as case management, crisis intervention services billed for a stay in an extended observation unit).
  • Billing for skills training without using a state-approved curriculum. 
  • Billing for unbillable activities per Medicaid billing guidelines (i.e. shopping or watching movies).

If providers receive a letter regarding recoupment or recovery, they will have the opportunity to submit an appeal. Please follow the rebuttal process outlined in the recoupment or recovery letter.

Clarification on the Rebuttal Process

After Superior’s Utilization Management department meets with the provider to discuss the findings of the review, Superior will share the feedback form with the provider. If the provider would like to rebut any of the findings, they must notify their assigned Superior Utilization Manager via email within 2 business days of receiving the feedback form. As a reminder, the rebuttal process of the retrospective review is optional.

If a provider chooses to submit a rebuttal, Superior must receive their comments (which can be provided on the feedback form) within 10 business days of receiving the feedback form. If Superior does not receive the rebuttal within 10 business days of receiving the feedback form, Superior will not be able to consider the rebuttal for the quarter’s review. Based on Superior’s review of the rebuttal, Superior will contact providers with comments on the feedback form and the final determination.

Additional Information

For any questions about required documentation, due dates or the retrospective review rebuttal process, please contact your assigned Utilization Manager or local Account Manager.