| Grade |
Criterion |
| Credentialing Burden |
|
| A |
Accepts "any willing provider": CV, license/certificate to practice in jurisdiction, and proof of malpractice insurance are sufficient to enroll practitioner. Credentialing decision made within 30 days |
| B |
Requires A and advanced credential (e.g., board certification, National Register listing) |
| C |
Requires A and/or B plus additional documentation eg application requiring up to 60 minutes to complete |
| D |
Requires C, plus application > 60 - 90 minutes with letters of reference, work samples |
| F |
Requires D plus extensive documentation eg application > 90 minutes to complete, work history for 10+ years, report of typical case mix |
| Credentialing Timeliness |
|
| A |
Decision about admission to the panel communicated within 28 days or less |
| B |
Decision communicated in 29 to 42 days |
| C |
Decision communicated in 43 to 56 days |
| D |
Decision communicated in 57 to 70 days |
| F |
Decision requires > 70 days, application lost, multiple requests for additional information, etc. |
| Paperwork |
|
| A |
None required beyond clinician's usual procedures, clinician judgment of practice-related standards of care, ethics, applicable laws |
| B |
Allows clinician-generated documentation if "utilization review" necessary in particular case |
| C |
Establishes timing and format of written treatment plan for all cases and/or required "outcomes" or "satisfaction" measures |
| D |
Establishes timing and format of most documentation, e.g., treatment plan, pre-authorization, re-authorization |
| F |
Establishes timing and format of all documentation, e.g., initial and updated treatment plans, progress notes, discharge summaries |
| Intrusiveness of "Case Management" |
|
| A |
Consistent with "Mental Health Consumers' Bill of Rights," requires disclosure only of diagnosis, prognosis, type of treatment, estimated length of treatment, to authorize coverage. Pre-authorization may be done in one telephone call |
| B |
Requires disclosure of specific information and details beyond "Bill of Rights" requirements. Pre-auth may require "internal" case management review prior to decision |
| C |
B-level review required plus "case manager" "suggests" alterations in treatment plan (e.g. referral for medication prior to psychotherapy) |
| D |
C-level rating plus case reviewer requires alteration in treatment plan in order to authorize care |
| F |
Requires extensive disclosure and specific examples of patient symptoms in written form prior to pre-authorization. Pre-auth typically takes at least two weeks and may require follow up by clinician to check status |
| Consideration of Patient Needs |
|
| A |
Routinely authorizes full benefit (e.g. 20 visits) based on clinician diagnosis. Allows client to present directly to clinician and does not require client to call case management system to describe symptoms. Allows client full choice of "on-panel" practitioners. |
| B |
Routinely authorizes partial benefit (e.g. 3 visits) and requests but does not require client to call case management system prior to authorizing initial visit |
| C |
Requires client to contact case management system to describe problem(s)/progress to authorize continued care after initial visits used |
| D |
Requires client to contact case management system prior to authorizing initial visit |
| F |
Routinely authorizes 1-2 visits for diagnosis only and requires client to call case management system to authorize initial visit and re-authorize continued care. Allows client no choice of clinician, provides names of "allowed" on-panel clinicians |
| Speed of Reimbursement |
|
| A |
Claims paid within 14 days or less 90% of the time |
| B |
Claims paid within 15 to 21 days 90% of the time |
| C |
Claims paid within 22 to 28 days 90% of the time |
| D |
Claims paid within 29 to 35 days 90% of the time |
| F |
Claims paid in 36 days or more 90% of the time |
