Peninsula Regional Support Network

TABLE OF CONTENTS

CHAPTER 1 - INTRODUCTION
1.01	Introduction, Mission
1.02	PRSN Organizational Overview Chart
1.03	Definitions and Common Language
1.04	Acronym Listing
1.05	General Duties and Responsibilities
1.06	Governance Structure and Community Accountability
CHAPTER 2 - ADMINISTRATION/INFORMATION POLICIES
2.01	Sentinel Events
2.01a	Sentinel Events Incident Reporting Form
2.02	Advance Directives
2.02a	PRSN Advance Directive Brochure
2.02b	DSHS Mental Health Advance Directive Brochure
2.03	Requirements with Changes to State Law
2.04	Medicaid Enrollment in the PRSN
2.05	Medicaid/TXIX Eligibility Verification
2.06	Comprehensive Information Plan for PRSN Delivery System and Services
2.07	General Information Requirements
2.07a	PRSN Handbook
2.07b	PRSN Handbook, Spanish, Revised 1-5-2012
2.07c	DSHS Medicaid Booklet, Revised 4-2010
2.08	Rehabilitative and Integrated Mental Health Treatment for Children, Adults and Older Adults
2.09	Provision of Priority State Funded Services
2.10	Provision of Additional State Funded Services
2.11	Enrollee Rights
2.11a	PRSN Client Rights Statement (out patient) Form - English
2.11b	PRSN Client Rights Statement (out patient) Form - Spanish
2.12	Consent for Treatment
2.13	Second Opinions
2.14	Interpreter Services & Assistance
2.14a	DSHS Transportation & Interpreter Services Brochure
2.15	Consumer Rights in Braille
2.16	Special Needs Accommodation Process
2.17	Special Populations - Coordination of Care for Children
2.18	Special Populations - Coordination of Care for Older Adults
2.19	Special Populations - Coordination of Care for Persons with Disabilities
2.20	Special Populations - Coordination of Care for Ethnic Minorities
2.21	Promoting Recovery and Resiliency
2.21a	Recovery: Promoting in Organizations, DSHS Publication
2.21b	Elements of Recovery, DSHS Publication
2.22	Protections Against Retaliation
2.23	Disaster Planning
CHAPTER 3 - NETWORK MANAGEMENT STANDARDS
3.01	Availability of Services
3.02	Culturally Competent Services
3.03	Culturally Competent Service Structure
3.03a	PRSN Directory of PRSN Specialists/Consultants
3.03b	PRSN Directory of PRSN Bilingual Agency Staff
3.03c	PRSN Directory of Tribal Specialists/Consultants
3.03d	PRSN Directory of Evidence Based Practices
3.04	PRSN External Specialist Consultation Services
3.04a	Attachment A - PRSN Special Population Evaluation Form
3.04b	Attachment B - PRSN Special Population Evaluation Form Instructions
3.05	Tribal External Specialist Consultation Services With Local Tribes
3.05a	Attachment A - PRSN Tribal Invoice Forms
3.06	Service Provider Selection
3.07	Service Provider Licensing Procedures - Application & Approval
3.08	Service Provider Staff Qualifications
3.09	Service Provider Credentialing & Recredentialing
3.10	Service Provider MHP Staff Exceptions
3.11	Notification of Network Agency Termination
3.12	Notification of Primary Mental Health Care Provider Termination
3.13	Appointment of DMHPs
3.14	DMHPs Accessing Profiler Protocol
CHAPTER 4 - MANAGEMENT INFORMATION SERVICES POLICIES
4.01	Loading of State Enrollment Data
4.02	Data Transfer to the Department
4.03	IS Data Submission Procedures
4.04	IS Encounter Submission
4.05	Data Error Resolution
4.06	Acceptance of Late MIS Data
4.07	Data System Backup and Recoverability
4.07a	Data System Backup and Recovery Testing
4.08	Management Attestation of Accuracy of Data
CHAPTER 5 - HIPAA AND MEDICAID COMPLIANCE STANDARDS
5.01	HIPAA Compliance & Privacy
5.01a	Kitsap County HIPPA Resolution
5.02	HIPPA Management Information and Confidentiality
5.03	HIPAA Administrative Requirements for Implementation & Maintenance
5.03a	HIPAA Policies Maintenance Plan
5.04	HIPAA Administrative Simplification Definitions
5.05	HIPAA Agency Staff Training
5.06	HIPAA PRSN Staff Training Plan for Privacy and Security
5.07	HIPAA Confidentiality, Use, Disclosure of Protected Health Information
5.07a	PRSN Privacy Notice, English
5.07b	Confidentiality and Security Agreement
5.07c	Business Associate Addendum
5.07d	PRSN Release of Information
5.07e	PRSN Oath of Confidentiality
5.08	HIPAA Consumer Protected Health Information Rights
5.09	HIPAA Administrative Requirements - Documentation Procedure
5.10	HIPAA Password Protection Procedure
5.11	HIPAA Workstation and Portable Computer Use Procedure
5.12	HIPAA E-Mail and Internet Security Policy
5.13	HIPAA Use of Fax Machines
5.14	HIPAA Designated Record Set
5.15	HIPAA Complaint Procedure
5.16	Breach Notification
5.16a	Breach Analysis, Form
5.17	Fraud and Abuse Compliance Reporting Standards
5.17a	PRSN Compliance Plan, FY 2012
5.17b	PRSN Compliance Plan Checklist, FY 2010-2012
5.17c	Fraud and Abuse Tracking Log Template
5.18	PRSN or Agency Use of Federally Excluded Providers
5.19	Credentialing and Recredentialing of Providers
CHAPTER 6 - COMPLAINTS, GRIEVANCES AND APPEALS POLICIES
6.01	Complaint, Grievance, Appeal and Fair Hearing General Requirements
6.01a	PRSN Grievance Brochure
6.02	Complaint and Grievance
6.02a	PRSN Grievance Form
6.02b	PRSN Grievance Acknowledgement Letter Template
6.02c	PRSN Grievance Resolution Letter Template
6.03	Appeal Process
6.03a	Commcare Appeal Acknowledgement ltr, template
6.04	Fair Hearing
6.05	Notice of Action Requirements
6.05a	Notice of Action (NOA) Form Letter Template
6.05b	Notice of Action (NOA) Form Letter, Spanish
6.05c	NOA Tracking Log
6.06	Grievance-Complaint Filing Procedure for PRSN for Providers
6.07	Complaint & Grievance Oversight and Recordkeeping
6.07a	Quarterly Agency Complaint Tracking Form
6.08	Exhibit N Report Instructions
6.08a	Exhibit N - Grievance Medicaid Reporting Form
6.08b	Exhibit N - Grievance Non-Medicaid Reporting Form
6.08c	Exhibit N - Appeals Medicaid Reporting Form
CHAPTER 7 - UTILIZATION MANAGEMENT POLICIES
7.01	Authorization for Outpatient Services based on Medical Necessity
7.01a	PRSN Authorization Notification Letter Example
7.01b	PRSN Authorization Notification Letter Example, Spanish
7.01c	PRSN Letter of Ineligibility Template
7.02	Authorization of Services - Independence from Financial Incentives
7.03	LOC: Condensed Version
7.03a	MHD Access Diagnosis - Adult & Older Adult
7.03b	MHD Access Diagnosis - Children & Youth
7.04	Intake Assessment and Evaluation Services Standards
7.04a	Outpatient Access & Authorization Standards Grid, 07-09
7.05	Peninsula Regional Assessment Tool (PRAT)
7.05a	PRAT Form (Profiler)
7.05b	PARS Form (Profiler)
7.06	Utilization Management Plan
7.06a	UM Monthly Report Template
7.06b	PRSN PRAT Report Template
7.06c	InPatient Retro & Appeals Summary Log Template
7.06d	InPatient Length Of Stay (LOS) report Template
7.07	Over and Under Utilization Projects
CHAPTER 8 - FISCAL MANAGEMENT POLICIES
8.01	Enrollee Liability for Payment
8.02	Financial Management
8.03	Third Party Liability & Coordination of Benefits
8.04	Management Attestation of Accuracy of Fiscal Reports
8.05	Fiscal Monitoring of Network
8.05a	Fiscal Monitoring Tool
8.05b	Budget Line Item Monitoring Protocols Tool
8.05c	Cost Allocation Monitoring Protocols
8.05d	FBG Monitoring Protocols
8.05e	Local Match Monitoring Protocols
8.05f	PATH Monitoring Protocols
8.05g	Revenue Monitoring Protocols
8.05h	Revenue & Expense Monitoring Protocols
8.06	Cost Allocations
CHAPTER 9 - PROVIDER MONITORING POLICIES
9.01	Monitoring Contractor and Subcontractor Sufficiency
9.02	Monitoring of Contractors
9.02a	PRSN Monitoring Table
9.03	Provider and Subcontractor Administrative Review
9.03a	Administrative Review Tool
9.03b	Administrative Review Personnel Checklist
9.03c	Administrative Review, Quality Plan Checklist
9.03d	Administrative Review, HIPAA Checklist
9.03e	BRIDGES Ombuds Administrative Review Tool
9.04	Subcontractual Delegation & Assessment Plan
9.04a	Subcontractual Delegation & Assessment Tool - ASO
9.04b	Subcontractual Delegation & Assessment Tool - IS
9.04c	Items of Delegation
9.05	Periodic Reviews of the E&T Facilities
9.05a	AIU and YIU Chart Review Tool, FY 2012
9.06	Periodic Review of Residential Treatment Facilities
9.06a	Residential Chart Review Tool
9.06b	Residential Facility Review Tool
9.07	Standard Chart Reviews
9.07a	Intake & Reauthorization Focused Chart Review Tool
9.07b	Crisis Chart Review Tool
9.07c	Zero PRAT Chart Review Tool
9.07d	Vocational Chart Review Tool
9.08	Quality Review Team (QRT)
9.08a	QRT Onsite Reviews Activities
9.08b	Family & Consumer Forum Protocols
9.08c	Ancillary Provider Interviews Protocols
9.08d	Ancillary Provider Interview Worksheet
9.08e	Agency On-site Visit Protocols
9.08f	Agency On-site Visit Interview Worksheet
9.08g	QRT Code of Conduct
9.08h	QRT Stipend & Reimbursement Form
9.09	Quality Review Team Retaliation
9.10	Provider and Subcontractor Non-compliance Penalties
9.11	Corrective Action Plans
9.11a	Corrective Action Plan Grid
CHAPTER 10 - QUALITY MANAGEMENT PLAN
10.00	Quality Management Plan Table of Contents
10.01	Quality Management Plan
10.02	Performance Improvement Projects
10.03	Quality Improvement Work Plan
10.04	Quality Indicators
10.05	Quality Management Organizational Chart
CHAPTER 11 - CLINICAL POLICIES AND PROCEDURES
11.01	Access to Services, Timely
11.02	Access to Services Prior to Intake Assessment - Medicaid Only
11.03	Services Modalities - Outpatient
11.04	Services Modalities - Crisis
11.05	Individual Service Plan/Treatment Plan Standards
11.06	Crisis Prevention Plan Standards
11.07	Crisis Response - Safeguarding Consumer's Property
11.08	EPSDT Coordination Plan and Requirements
11.08a	EPSDT Dr. Referral Form
11.09	PACT Stakeholders Advisory Board
11.10	Employment Services
11.11	Housing Services
11.11a	PRSN Housing Plan, FY 2012
11.11b	PRSN Housing Grid, 2012
11.11c	PRSN FBG Housing Projects, 2012
11.11d	KMHS Housing Plan, 2012
11.12	Homeless Individuals, Providing Services
11.13	Criminal Justice System, Providing Services
11.14	Practice Guidelines
11.14a	Schizophrenia Condensed Guidelines
11.14b	Bi-polar Disease Condensed Guidelines
11.14c	Practice Guidelines Chart Review Tool
11.15	Option to Choose a Mental Health Care Provider/Clinician
11.16	Notification of Primary Mental Health Care Provider Termination - Medicaid Only
11.17	Provider Purchasing Out of Network Services
11.18	Primary Medical Care Provider and Hospital Emergency Rooms, Coordination of Care
11.19	Special Health Care Needs - Services and Coordination of Care
11.20	Special Healthcare Needs - Direct Care, Treatment Planning and Access to Mental Health Professionals
11.21	Special Healthcare Needs - Mechanisms to Assess Quality and Appropriateness of Care
11.22	Use of Seclusion and Restraint
CHAPTER 12 - INPATIENT POLICIES
12.01	DSHS Inpatient Instructions Per Diem, 8-07
12.01a	Form: E & T Admission Certification Form
12.01b	Form: E & T Extension Request Form
12.01c	DSHS Instructions Update: Memo 0108 - Retro Authorizations for TPL
12.01d	DSHS Instructions Update: Memo 0208 - ITA Authorization
12.02	Voluntary Inpatient Gatekeeping
12.02a	Voluntary Hospital Certification Process for Children
12.02b	Voluntary Hospital Certification Process for Adults
12.03	Voluntary Inpatient Denials
12.04	Network Assignment of Inpatient Costs - ITA and Voluntary
12.04a	Inpatient Bill Assignment - Frequently Asked Questions
12.05	Admission and Discharge Coordination from Inpatient Care
12.06	Emergency Services Transportation
12.07	Single Bed Certification-Approval
12.07a	Single Bed Certification Form
12.08	Children's Long-Term Inpatient Program (CLIP) Coordination
12.08a	CLIP Admission Procedure
12.09	Western State Hospital Program Coordination
12.09a	WSH Protocols for Discharge of DDD Clients
12.09b	WSH InterRSN Transfer Protocols
12.09c	WSH InterRSN Notification of Consumer Relocation Form
12.09d	WSH Dispute Resolution Process
12.09e	WSH Review Tool, FY 2012
CHAPTER 13 - ADVOCACY AND SUPPORT PROGRAMS/POLICIES
13.01	Mental Health Care Professional Advocacy
13.02	Ombuds Services
CHAPTER 14 - PRSN CROSS SYSTEM WORKING AGREEMENTS
14.01	PRSN Cross System Working Agreement
14.01a	PRSN Cross System Working Agreements Schedule
14.02	Healthy Option Coordination Policy

Working Agreements (not included in paper version of manual)
DDD (Division of Developmental Disabilities) - Adult
DDD (Division of Developmental Disabilities) - Child
DCFS (Division of Child and Family Services)
WSH (Western State Hospital)
CLIP (Children's Long-term Inpatient Program)
Long Term and Aging
7.01 Bi-Annual Plan and Yearly Update
JRA (Juvenile Rehabilitation Administration)

Index