MCO Requirements for Coordinating Treatment Foster Care (TFC) Placements for Children in State Custody (CISC)
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This Letter of Direction mandates Centennial Care 2.0 MCO responsibilities for confirming medical necessity, prior authorization, coordination, documentation, and quarterly reporting when Children, Youth, and Families Department (CYFD) refers children in state custody for Treatment Foster Care (TFC). It affects New Mexico MCOs and their care coordinators who serve CISC enrollees.
New processes requiring MCO care coordinators to coordinate and obtain TFC services for children in state custody effective August 15, 2023.
Treatment Foster Care (TFC) Coverage and Decision Workflow
TFC authorization and disposition workflow
Coverage and decision workflow for TFC referrals from CYFD to MCO:
If the MCO reduces, denies, modifies, or delays TFC
- Notice of Action and grievance protocols must be provided to the child’s caregiver, legal representative, and legal custodian.
- Any denial, reduction, modification, or delay will be reviewed by the MCO Medical Director and a copy of the Medical Director’s decision must be sent to the Cabinet Secretary of HSD and the Cabinet Secretary of CYFD.
- Any Notice of Action received by CYFD will be provided to the child’s Nation, Pueblo, or Tribe if applicable.
Prior Authorization, Pre-approval, and Appeal Process
Submit referral/assessment to MCO; MCO pre-approval, prior authorization, appeals, and reporting obligations
CYFD must submit the referral packet and current assessment to the MCO so the MCO can complete the medical necessity review and issue pre-approval; the MCO care coordinator issues full prior authorization with a prior authorization number once a TFC placement is identified. If the MCO reduces, denies, modifies, delays, or does not approve TFC (including prior authorization requests), the MCO must provide a Notice of Action and grievance protocols to the child's caregiver, legal representative, and legal custodian; the MCO Medical Director must review any denial/reduction/modification/delay and the Medical Director's decision must be sent to HSD and CYFD. If TFC is not authorized, HSD and/or CYFD will identify alternative services within 5 days and may consider single case agreements; the MCO must report the determination and timing (days between request, approval, and service start) and submit specified data quarterly.
- CYFD submits referral and current assessment to MCO for medical necessity review and pre-approval; MCO sends pre-approval notification when medical necessity is met and issues full prior authorization once placement is identified. (chunk 1)
- MCO care coordinator documents activity in the child's MCO file per contract obligations. (chunk 1)
- If reduced/denied/modified/delayed/not approved, MCO provides Notice of Action and grievance protocols to caregiver, legal representative, and legal custodian; Notices received by CYFD must be provided to the child's Nation/Pueblo/Tribe if applicable. (chunk 1)
- Any denial/reduction/modification/delay (including for prior authorization requests) will be reviewed by the MCO Medical Director and the Medical Director's decision is sent to the Cabinet Secretary of HSD and the Cabinet Secretary of CYFD. (chunk 2)
- If TFC services are not authorized, HSD and/or CYFD will identify alternative services within 5 days and may consider single case agreements; during appeal the IPP Team will place the child in the most appropriate and least restrictive placement. (chunk 2)
- The MCO must report the determination (approval/denial/modification/reduction/delay) and include timing (number of days) between request, approval, and start of TFC services; MCOs must submit specified aggregate and child-level data quarterly. (chunks 2 and source brief)
Coding and Billing References
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