Continued Care: Transitioning Levels of Care

During a patient’s treatment, clinicians often initiate care at a higher Level of Care (LOC), such as Detoxification (Detox), to facilitate medical and psychological stabilization. Once stabilization is achieved, the patient transitions to a lower LOC based on their clinical needs. In Kipu, these transitions are carefully documented to ensure compliance and accuracy.

Required Permissions: Admin, Therapist, Case Manager, Biller, Utilization Review Internal, Record Admin, and Super Admin.

Levels of Care in Kipu 

• Utilization Review (UR) Level of Care: This LOC represents the level for which authorization is requested from the patient’s insurance provider to obtain reimbursement. It corresponds to the services being billed.
• Clinical Level of Care: This LOC reflects the actual treatment level provided based on the patient’s clinical needs. Typically, the Clinical LOC aligns with the UR LOC. However, when insurance denies authorization for the requested level, the facility may choose to continue treatment at the higher clinical LOC to address the patient’s needs, even if reimbursement is limited to a lower UR LOC.

The LOC can be configured to match facilities' needs. By actively monitoring and managing LOCs, facilities ensure patient-centered treatment while maintaining compliance with insurance requirements and internal policies. The table below indicates the Standard LOC and the corresponding LOC type.

Best Practice: Use standardized naming conventions for UR/Clinical LOCs.

Best Practice Workflow Video

Standard LOC Vs. Kipu LOC Type

Standard LOC	LOC Type in Kipu
Outpatient (OP)	Outpatient (OP)
Outpatient detoxification	Outpatient (OP)
Outpatient methadone/buprenorphine or naltrexone treatment (OTP)	Outpatient (OP)
Outpatient buprenorphine or naltrexone treatment (OBOT)	Outpatient (OP)
Intensive Outpatient Program (IOP)	Attendance Based (PHP/IOP)
Partial Hospitalization/day Program (PHP)	Attendance Based (PHP/IOP)
Short-term residential	Inpatient (Detox/Res)
Long-term residential	Inpatient (Detox/Res)
Residential detoxification	Inpatient (Detox/Res)
Hospital inpatient/24-hour hospital inpatient	Inpatient (Detox/Res)
Hospital inpatient detoxification	Inpatient (Detox/Res)

Best Practice Workflow Steps 

Let's review Kipu EMR's best practice workflows to transition LOC.

Workflow 1: UR Team Requests Authorization for Change in LOC

The Utilization Review (UR) team requests insurance authorization for the next LOC by contacting the patient’s Insurance Care Manager. This process typically involves a scheduled phone call, with relevant details documented in the insurance section of the patient’s facesheet. The Insurance Care Manager is an employee of the insurance company, not the facility.

Workflow 1A: Insurance Approves Requested LOC

• Click on the Information tab.
• Scroll to the Utilization Reviews section and click +Add LOC Review.
• Update the UR LOC in the authorization form including Number of Days, Authorization Number, Next Review Date.
  
• Select the Status from the drop-down list and click Save Authorization.

• Best Practices: Use the New status immediately after creating a utilization review to indicate it is in draft and not yet submitted. Change the status to Pending once the review is formally submitted for approval, and update it to Approved or Denied only after receiving formal authorization or rejection, respectively. Create a new utilization review when the patient receives a new authorization number, a new Level of Care is authorized, an existing Level of Care is extended with a new authorization number, or the patient transitions between Levels of Care (e.g., Residential to Detox). Update an existing utilization review instead when the authorization is extended without a change in authorization number or when its status is updated (e.g., from New to Pending or from Pending to Approved/Denied).

Workflow 1B: Insurance Denies the Requested LOC 

This workflow supports clinical decision-making while ensuring accurate documentation and compliance with insurance and regulatory standards. If the insurance provider denies authorization for the requested LOC, approving either a lower LOC or no coverage at all, the facility determines the next course of action, including:

• Continue Treatment at the Higher Clinical LOC: The facility provides care at the higher clinical LOC based on the patient’s needs but bills insurance at the lower approved UR LOC.
• Discharge and Refer the Patient: The facility ends the patient’s episode of care and refers them to a provider specializing in the appropriate LOC.

In both scenarios, follow the steps below:

1. Add the Manage Clinical LOC form to the patient’s chart using the centralized documentation icon.
   
2. A Case Manager or Clinician enters the date of change and transition to LOC information.
   
3. Update the facesheet to reflect the denied status of the requested UR LOC if the service has already been provided.
   

   • Note: Change the status to Denied only after receiving the formal rejection.

Workflow 2: Request Authorization for Continuation in the Same LOC

Workflow 2A: Insurance Approves the Requested LOC

1. A user from the UR team clicks +Add LOC Review in the patient’s facesheet to create a concurrent review authorization.
2. Enter the number of days, same UR LOC, authorization number, next review date, and Approved status in the appropriate fields.

   • Note: Update the status to Approved after receiving the formal authorization.

3. Enable Notifications to alert the Care Team of upcoming reviews and LOC changes, ensuring seamless communication. These steps will help staff confirm chart compliance before insurance requests and provides the UR team with accurate information for appropriate LOC requests.

Workflow 3: Patient’s Treatment Not Covered by the Insurance.

When a patient does not utilize insurance, the payment method is designated as Private Pay or Scholarship.

• Private Pay: The patient pays the facility an agreed-upon rate for their treatment.
• Scholarship or grant-funded care: The patient may be responsible for partial payments or no payments, depending on the terms of the funding arrangement.

Follow the steps below to ensure accurate tracking of financial arrangements and adherence to clinical protocols:

1.  Add a new Manage Clinical LOC form to the patient’s chart using centralized documentation icon. 
   
2. A Case Manager or Clinician enters the date of change and transition to LOC information in the relevant fields.