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Claims & Appeals Process

Q: Do providers need to submit a form for the second level appeal?
A: Yes, the updated form will have the option to select if it is a first level or second level appeal.

Q: What is the difference in the second level appeal?

  1. To give the provider the opportunity to submit additional information to support the claim
  2. A second review to ensure nothing was missed or changed dusring the first review

Q: What form would providers use to submit a third level review to SWMBH?
A: Providers should use the Summit Pointe appeal form to indicate “Level 3- SWMBH” on the appeal form. This information will be sent to SWMBH for review.

Q: Would overlapping services be a reason to appeal?
A: Yes. You would need to submit the documentation to the support the services and the time(s) the services were provided (face-to-face programming time).

Q: What is the expected response time when we submit an appeal?
A: Thirty calendar days from the date the appeal was submitted.


Trends in Compliance

Q: Which areas (in the “Trends” section) were repeat citations?

  1. Staff trained on the IPOS
  2. Documentation of providing choice to customers
  3. Documentation of opportunities for customers/guardians to provide feedback on services.

Q: Are providers supposed to be documenting on everything in the plan, including all of the information in the narrative section of the intervention?
A: Summit Pointe is making and effort to focus on basic “Case Management 101” techniques. We are training our staff to ensure they are using SMART goals and objectives. The narrative in the intervention is the “how.” It is how the provider will assist the customer to master their objectives to achieve their goals. It is important for providers to work with the case manager to ensure the intervention section corresponds with the services being provided. Also, providers should check the intervention section to verify what goals and objectives pertain to the services that the agency is providing. Providers should document on those goals, objectives, and interventions that apply to your agency.


Behavior Plans

Q: Can Summit Pointe coordinate the providers to do one meeting for the behaviors plan training and updates?
A: Yes. We can work with the BCBAs to start doing this process.

Q: Behavior plan tracking sheets- How do providers track behaviors, such as tantrums, that last 3-4 hours? Does that go one one tracking sheet with the start and stop time?

A: The plan should indicate how to document these incidents. If the behavior did last that long, please include as much information as you can to support and provide information related to the behavior on the data tracking sheet. The BCBA will also want to look at additional information such as the daily progress notes.

Q: How do providers know when the plan expires? Can we get documentation of it?

A: The plans do not technically expire, however the BCBAs are required to review and update the plan annually. The plan should go no longer than a year without review. If a provider has plans that have not been reviewed in a year, please contact Sean Field. The BCBA should be providing a discharge summary along with recommendations for future supports.

Q: Providers are still having a lot of difficulty getting the signature page of the behavior plan with the guardian’s signature. Is there a process in place to address this?

A: In the last month, Summit Pointe has developed an internal tracking system. If you continue to see this issue and are unsuccessful getting a copy from the case manager, please notify Sean Field or Bridget Avery.


Home and Community Based Services

Q: Are restrictions, such as having knives locked up, now going to require the customers to have a behavior plan?

A: In most cases, no. These type of restrictions will need to be addressed in the treatment plan.

Q: For the HAB Waiver CAPs, if it is a program issue notified, can the provider submit a CAP for the whole program? Or, do the providers need to have individual CAPs with the same issue identified for each customer?

A: You still need to address it on the individual level. The recommendation is that you list all of the WSA numbers that each programs issue applies to.

Q: Do providers need to CC anyone at Summit Pointe when submitting a CAP to SWMBH?

A: Yes, please CC Elizabeth Wygant.

Q: Providers are still seeing that case managers are listing that the customer will abide by house rules in the treatment plan. Can this be addressed as it does not align with the HCBS rule?

A: Yes.


Q: Are the Summit Pointe training requirements the same as the SWMBH training requirements?

A: Yes, with the exception of the Recipient Rights training and CPR training. These need to be completed prior to working with customers. This exception is outlined in the contract.

Q: Is Summit Pointe still accepting the “train the trainer” for IPOS training and behavior plan training?

A: Yes.