Download DMH Adult Clinical Service Authorization

Applying for Adult
Department of Mental
Health (DMH) Services in
Massachusetts
Felice De Ruggiero, LICSW, LADC-1
Adult Clinical Service Authorization Unit
DMH Northeast Area, Tewksbury
Objectives

Summarize the Adult DMH determination
process and eligibility criteria
 Assess an applicant’s immediate or emerging
needs in relation to eligibility criteria
 Identify the steps in the appeals process
 Submit a comprehensive DMH adult application
in order to secure appropriate clinical and
professional services for the applicant
Applicants for Adult Services

The adult application must be signed by the
applicant or the legal guardian (DCF guardian,
custodial guardian or permanent legal guardian)
 Include a copy of the guardianship decree or the
DCF Care and Protection order
 Include DMH two-way releases of information
signed by the applicant or legal guardian for all
psychiatric hospitalizations in the past 5 years,
any neuropsychological testing reports,
residential programs, and outpatient providers
 If
there is a history of substance abuse,
the applicant or their guardian must initial,
sign, and date the Protected Health
Information Section on the second page of
the release in order for DMH to obtain
records
 Submit as much current clinical
information as possible with the
application
 Summarize
the Adult DMH determination
process and eligibility criteria
 What happens when the application is
received
 What diagnoses are qualifying vs. nonqualifying
Qualifying vs. Non-Qualifying
Diagnoses
From Commonwealth of Massachusetts DMH Interpretive Guidelines for 104 CMR 29.00
Determining Service Authorization for Children Adolescents and Adults, December 2011)

Qualifying diagnoses:
 Schizophrenia, Schizoaffective Disorder, Psychotic
Disorder, NOS
 Mood Disorder, NOS, Depressive Disorder, NOS, Major
Depressive Disorder, Bipolar Disorder
 Anxiety Disorder, NOS, Generalized Anxiety Disorder,
Panic Disorder with or without Agoraphobia, Obsessive
Compulsive Disorder, Social Anxiety Disorder, PTSD
 Dissociative Identity Disorder, Delusional Disorder
 Anorexia Nervosa, Bulimia
 On Axis II: Borderline Personality Disorder (the only
qualifying Axis II diagnosis)
Non-Qualifying Diagnoses






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Adjustment Disorder, Dysthymia, Cyclothymia
Schizophreniform Disorder
ADHD
Any disorder that is due to a medical condition
(i.e. Mood Disorder Due to a Medical Condition,
Substance-Induced Mood Disorder, etc.)
Dementia
Delirium
Cognitive Disorder, NOS
Non-Qualifying Diagnoses,
Continued
 Traumatic
Brain Injury or Head Injury
 Mental Retardation
 Learning Disorder, NOS
 Autism Spectrum Disorder
 Pervasive Developmental Disorder
 Asperger’s Syndrome
 Any personality disorder other than
Borderline
A Word About Substance Abuse
From Commonwealth of Massachusetts DMH Interpretive Guidelines for 104 CMR 29.00
Determining Service Authorization for Children Adolescents and Adults, December 2009
(Revised December 1, 2011)

An individual with a substance abuse problem is eligible
if he or she is determined to have a qualifying mental
disorder, meets impairment and duration criteria,
requires DMH continuing care services, and has no other
means for obtaining them. The qualifying mental
disorder must be confirmed before assessing whether
the applicant meets duration and functional impairment
criteria. Functional impairment will be determined based
on the applicant’s presentation. It is presumed that the
functional impairment in a person with a co-occurring
disorder is due to the primary psychiatric diagnosis.
Needs and Means Determination

How is it determined if the applicant has a need
for a DMH service?
 A site representative conducts an informal in
person interview with the applicant or their legal
representative
 The applicant is asked why they are applying for
services and what kind of services they think
they need
 The site determines whether the service can be
obtained through other means (i.e. through
insurance or another state agency)
Needs and Means Approved

If approved overall, what services can be received?
 Case Management vs. CBFS: What is the difference?
 Case Management (CM)= Brokerage & linkeages
 CBFS= Community Based Flexible Supports that
provides wrap around programming with a team with
intensity of service fluctuating based on need
 Both CM and CBFS can assist with vocational training,
housing referrals, health and wellness referrals, and
residential placement
 A word about DMH and housing....
What happens if there is no need
for a DMH service?

Applicants can be denied on need if they can
obtain services through other means, are
assessed to have no need for a DMH service, or
if they decline/refuse DMH services
 Applicants who are found to meet the clinical
criteria for DMH services but are denied on need
remain clinically authorized for 6 months. If their
situation changes, a new application is not
needed if they wish to reapply during this time
period, but they will need a new Needs/Means
interview at the site to reassess their need for a
DMH service.
What about clients who were
previously served by DMH?

If a client was previously served, they will remain
meeting the clinical criteria for 1 year from the date that
their case was closed
 They will not need to fill out a new DMH application if
they want to reapply within the one year time frame
 A new Needs/Means interview will be required at the site
level to determine if there is still a need for a DMH
service
 Prior to filling out a DMH application, have the client sign
a release of information to check on their Service
Authorization status. It could save you a lot of work!
Appealing a Denial
 Identify
the steps in the appeals process
 Gather support letters from current
providers that outline the symptoms that
support the diagnoses
 Importance of the face to face interview
 Present any new documentation to
support the application at this time
Application Cheat Sheet
Make sure to include:
An application that is signed and dated by the applicant or their legal
guardian
Guardianship decree, if applicable
DMH two way releases completely filled out and signed, initialed and
dated by both the applicant and guardian for all psychiatric
hospitalizations in the past 5 years, any neuropsychological testing
reports, any residential programs, and outpatient providers
A support letter from a clinician (therapist or psychiatrist) outlining Axis
I-V diagnoses and the specific symptoms that support those
diagnoses
Submit as much clinical information as possible with the application
In Summary
 Questions