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Children's Behavioral Health Services

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Residential Treatment Approval Process

**t is important to note that the Intensive Temporary Residential Treatment (ITRT) process must be followed at all new admissions and when a youth is being moved from one facility to another even if this facility is within the same agency. 

  1. 1. When there is conversation within a child’s team about the possibility that residential treatment may be appropriate for a child, the child’s case manager/caseworker calls the Office of Child and Family Services (OCFS) Mental Health Program Coordinator (MHPC) as soon as possible and discusses the case scenario. The OCFS Mental Health Program Coordinator and case manager/caseworker will decide together what will occur next. A Team Meeting may be scheduled at this point in which the OCFS Mental Health Program Coordinator will be invited to explore treatment options with the team. If residential treatment is indicated, the child’s case manager/caseworker completes the ITRT application and collects the appropriate clinical documentation, and then submits both the application and the clinical documentation to the OCFS Mental Health Program Coordinator.  
    1. a. Clinical documentation requested as available (this is not an all inclusive list of documentation; hence, Mainecare Benefits Manual Chapter II, Section 97.02 should be referenced for the criteria that must be met in order to be prior authorized for this treatment service, and any current clinical documentation that will support these criteria being met should be submitted along with the ITRT application):
      • Comprehensive psychiatric evaluation with Axis I-V included; psychological evaluation; psychosocial assessment; Current (done within 10 days of submission of application for ITRT) Children’s Habilitation Assessment Tool (CHAT) with description of specific symptoms justifying the score, Global Assessment of Functioning (GAF) with description of specific symptoms justifying the score, and/or Child and Adolescent Functional Assessment Scale (CAFAS) with description of specific symptoms justifying the score.
      • Current treatment plans of providers involved and/or letters from current treatment providers stating goals/objectives and progress made/barriers to overcome. There must be clear documentation as to why the child’s needs cannot be met with intensive community based services. If the child currently has a psychiatrist caring for them, a letter from the psychiatrist is requested documenting the need for out-of-home treatment and why these needs cannot be met in the community.
      • Discharge summaries from past providers (within the last year) that note goals/objectives met/not met and treatment recommendations at discharge from their service, including documentation from recent hospitalizations and/or crisis unit stays.
  1. 2. An OCFS regional review team reviews the application and clinical documentation and determines if the child meets criteria for admission to residential treatment utilizing the criteria specified in the Mainecare Benefits Manual Chapter II Section 97.02. The OCFS Regional Review Team consists of the Mental Health Program Coordinators, Utilization Review Specialists, Child Welfare staff (as designated by the CW Program Administrator), and the Children’s Behavioral Health Services (CBHS) Team Leader . The Mental Health Program Coordinators present the documentation given to them by the community team to the OCFS Regional Review Team.
  2. 3. A.) If the OCFS Regional Review Team decides that the child meets criteria for admission to residential treatment, the child’s guardian and case manager/caseworker will be notified by the OCFS Utilization Review Specialist via approval letters. An approval to move forward in the process letter will also be faxed to the recommended residential treatment providers by the Mental Health Program Coordinator (the residential treatment agency/agencies will be recommended by the regional team but proposals for specific residential treatment providers by the child’s community team will be taken into consideration – if there is disagreement by the community team about the recommended treatment providers, the MHPC should be contacted to pursue further discussion around this so that other recommendations can be made if appropriate). Only after receiving the approval for moving forward in the process letter from OCFS, should the agency assume that OCFS is in agreement of a possible admission. All referral forms/documentation required by the residential facility will be submitted by the guardian and/or case manager/caseworker. Move on to step #4 of this process.

    OR

    B.) If the OCFS Regional Review Team decides that the child does not meet criteria for admission to residential treatment, the Mental Health Program Coordinator will contact the case manager/caseworker with treatment recommendations. A denial letter will also be sent to the guardian and case manager/caseworker with these recommendations as well as the rights to appeal attached. The process would end here.
  1. The proposed treatment agencies will then review all documentation available as well as conduct a face to face interview with the child and family/CW guardian. The agency will then develop an Initial Individualized Treatment Plan to address the 1st 30 days of treatment which will be submitted to the OCFS Utilization Review Specialist. The OCFS Utilization Review Specialist will review the treatment plan with in three business days of receiving it from the agency and may suggest changes to the agency.
    1. Utilization Review Specialist is looking for the following in an initial treatment plan:
      • Treatment focusing on the specific reason the child was approved for residential treatment. Treatment modalities being used should be specified.
      • Clear statement of why the child requires this level of care for treatment.
      • Individual goals and objectives for the child, family goals and objectives, and who is responsible to deliver these services.
      • Clear discharge criteria, including a tentative discharge date.
      • Clear transition plan that notes how reintegration back into the community will occur over time with target dates (i.e. so many visits and treatment sessions at the program; so many day visits at home with treatment with clinician processing these visits, so many overnights with treatment with clinician processing these visits, etc.)
      • Provider Billing ID
  1. Once any needed changes to the Initial Individualized Treatment Plan are made by the residential treatment agency, the OCFS Utilization Review Specialist will give final approval for the child to be admitted to the designated residential treatment facility. The Utilization Specialist will communicate with the treatment agency via a letter that will give final approval, Mental Health or Mental Retardation/Pervasive Developmental Disorder designation, and Level I or II designation with rate. If the residential treatment agency is in disagreement with the level designation/rate, the agency can appeal using the process specified in MaineCare Benefits Chapter I, Provider Appeals.
  2. The approved residential treatment provider will contact the OCFS Utilization Review Specialist on the day of admission to the facility to request Prior Authorization be entered into the APS Care Connection system. The Utilization Review Specialist will confirm with the provider that the correct Billing ID is the one on the initial treatment plan at this time.
  3. The OCFS Utilization Review Specialist will enter the child into APS Care Connection within 1 business day of being informed of the admission date to the residential facility. This entry into APS Care Connection is a Prior Authorization submission and will include the provider’s Billing ID, Location, BR code if appropriate, designation of level within residential treatment, and relevant clinical information used to make the level of care determination.
  4. The APS Care Manager will confirm the OCFS prior authorization, process the review and assign the PA number from MECMS. The PA number will then appear in the Download Notification within APS Care Connection.
  5. The OCFS Utilization Review Specialist will be involved as needed once the child is admitted to the residential treatment facility with the purpose of assisting with difficult discharges which may be related to a variety of barriers.  
  6. APS Healthcare will be utilized for continued stay requests for any child in residential treatment. When the first continued stay request is due, the residential treatment provider will extend off of the Case ID (PA) that OCFS created at the time of admission.
  7. The residential treatment provider is responsible for submission of any Continued Stay Requests and discharges in APS Care Connection.

General Information Related to the Process:

  • The OCFS decision making process for Prior Approval of Intensive Residential Treatment typically takes 5-7 business days if all relevant clinical information has been presented to the clinical review team.  
  • Each OCFS region meets on a weekly basis on a designated day. All ITRT applications with attached clinical documentation must be received by the OCFS Mental Health Program Coordinator no later than 2 business days prior to the designated weekly review day of that region in order to be presented that week. Region 1/Districts 1 & 2 meet on Tuesday. Region 2/Districts 3, 4, & 5 meet on Thursday. Region 3/Districts 6, 7, & 8 meet on Tuesday.
  • If an application is submitted to OCFS and there is insufficient clinical documentation making it impossible to make a level of care determination, an administrative denial letter will be sent to the guardian and case manager/caseworker. This will allow the missing documentation to be submitted within 7 business days. If the missing documentation is received within 7 business days, the ITRT application will be reviewed and a decision will be given. If the missing documentation is not received within 7 business days, the application will be considered administratively denied, and a new application with documentation would need to be submitted in the future if appropriate.
  • If a child is approved for residential treatment, and the child does not enter residential treatment within 60 days of this approval, a “Request for Extension of Approval of Intensive Residential Treatment Services” form (attached to all approval letters sent out) must be submitted to the OCFS Mental Health Program Coordinator by the caregiver with assistance from the case manager/caseworker as appropriate. This form must be faxed/post marked no later than 7 days prior to the end of the 60 days or OCFS may request a new application. The MHPC will discuss the request with the Regional Review Team and a decision will be made to either approve the request or require that a new ITRT Application be submitted with attached updated clinical documentation.
  • Should a situation arise where an expedited decision be necessary, the case manager/ case worker will fill out the ITRT application, collect clinical documentation, and request an emergency meeting via the OCFS MHPC (all clinical documentation necessary to make a level of care determination must be submitted in order to proceed with an emergency presentation and all steps within the regular process will take place with the exception of certain time frames). The OCFS MHPC will decide if an expedited decision is appropriate. If it is decided that it is appropriate, an emergency meeting will take place and must include at least 3 people from the regional review team. This group of 3 people must include a Utilization Review Specialist. If the OCFS MHPC decides that an expedited decision is not appropriate, than the regular process with specified time frames would apply. All attempts should be made to avoid emergency meetings in order to provide ample time to make appropriate treatment decisions for the child.    
  • Admission to a residential facility should never occur in the absence of this process. PNMI and Room and Board funding are directly tied to being approved through this process.
  • All decisions for residential treatment must be approved by a Utilization Review Specialist. In the event that the regional review team is unable to come to agreement on the most appropriate treatment option, the Utilization Review Specialist will present the case to the OCFS Medical Director who will review the case and make the final determination.
  • The OCFS staff and APS Healthcare staff will be communicating around difficult situations/cases.
  • If there is a circumstance where increased staffing within a residential agency appears to be appropriate, the residential provider should contact the OCFS UR Specialist for potential Prior Authorization and the process that accompanies this.
  • The regional CBHS Team Leader should be contacted if concerns arise regarding this process.

OCFS Regional Contact Information:

  • Region 1/Districts 1 & 2 –
    • Mental Health Program Coordinator:
      • Michelle Descoteaux  (207)822-0355
    • Mental Health Program Coordinator/DOC Liaison:
      • Vacant position – contact Brenda Gagnon, Regional Supervisor at (207)822-0298
    • Utilization Specialists:
      • Jim Allen (207)822-0489
      • Jennifer Dondero (207)822-0245
    • Team Leader:
      • Rachel Posner (207)822-0246
  • Region 2/Districts 3, 4, & 5 –
    • Mental Health Program Coordinators:
      • Judy Adams (207)624-5251
      • Sandra Worthington (207)795-4521
    • Mental Health Program Coordinator/DOC Liaison:
      • Rick Meagher (207)743-3924
    • Utilization Review Specialists:
      • Michele Walters (207)795-4520
      • Rachel Booker (207)624-5256
    • Team Leader:
      • Kathy Alley  (207)624-5252
  • Region 3/Districts 6, 7, & 8:
    • Mental Health Program Coordinators:
      • Jane Sawyer (207)561-5003
      • Randy Browne (207)532-5030
    • Mental Health Program Coordinator/DOC Liaison:
      • Jeff Leonard  (207)941-3140
    • Utilization Review Specialists:
      • Susan Dubay (207)941-4356
      • Jamie Farren (207)561-4209
    • Team Leader:
      • Theresa Barrows (207)941-4363