Page 20 indicates - "Contact the MCO's care management team when an event-based reassessment occurs......"   will there be easily readily direct contact information made available for this and other required contact to the MCOs?  Currently when attempting to call in or ask about Mental Health Skill Building authorizations it can be difficult for individuals on either the member services OR provider services lines to get you through to an applicable person because the teams who handle those sorts of Medicaid based authorizations seem to be parts of the MCO that are different than those who typically handle other sorts of prior authorizations - for instance those who call to advise was sent for peer review do not leave their direct contact info, but reference calling in for a peer review request and usually the individuals  who schedule those have very limited info.  It can also be difficult (or impossible) to obtain information about a member's MCO Care coordinator as different MCOs have various different processes for this (UHC for instance says they cannot disclose this info to providers) and also different names for this position - some appear to not have them, some call them case managers, etc.  

Can we get a guidance document that contains specific and direct contact information for each MCO and FFS for each instance of required contact referenced in this and other new drafts to the insurance plans regarding the above referenced mention as well as other instances where direct communication to them is required?  It would also need to be consistently updated if/when changes occur.

Just N Time submits these comments in its consulting capacity, advising behavioral health agencies preparing for CPST and CSC. These comments request practical implementation guidance and do not represent statements about any individual client agency's compliance.

1. Billing responsibility. Please specify who may bill for an assessment when a certified QMHP completes ratings and a separately qualified clinician completes the diagnostic evaluation and formulation. Clarify rendering and billing provider requirements, whether components may be completed by different agencies, duplicate-billing controls, permitted codes and units, same-day restrictions, and what work is included in the service payment. Please provide examples distinguishing separately billable comprehensive reassessments from periodic updates included at the service level.

2. Reassessment timing. Please publish a single schedule distinguishing initial assessments, routine updates, annual reassessments, and event-triggered reassessments. Define the events that trigger a new assessment, the completion deadline, how timing relates to authorization expiration and ISP review, and which requirements apply to members transitioning from legacy services. Explain how care and payment will be handled while an updated assessment or authorization is pending. Include examples for both adult and youth CPST and CSC.

3. Assessor and supervisor certification. Please clarify whether CANS certification is required of every clinical supervisor, only individuals co-signing CANS, and/or the diagnosing clinician who signs the clinical formulation without independently assigning ratings. Identify approved training, the definitive passing standard, renewal requirements, evidence accepted for verification, and the consequences of certification lapses. Publish training availability and expected costs early enough for agencies to prepare.

4. Diagnostic signatures. Please identify which practitioner credentials may complete and sign each assessment component, including supervised practitioners. Clarify whether an existing diagnostic evaluation may be incorporated, acceptable timing between ratings and diagnostic signatures, and how corrections or disagreements between clinicians should be documented.

5. EHR feasibility and conditional modules. Please publish the final data dictionary, age-specific requirements, trigger logic, mandatory-versus-optional module list, and version-control expectations. Clarify whether an integrated EHR assessment that preserves all required content is acceptable instead of reproducing the state's template exactly. Specify acceptable electronic signatures, amended-record audit trails, export formats, and any required submission platform or interface. Allow sufficient vendor implementation time after final specifications are released.

6. Authorization attachments. Please issue a uniform checklist identifying precisely what must accompany initial and continued-service requests for managed care and fee-for-service. Explain whether the entire combined assessment, a structured extract, or other documentation is required, how the agency will verify receipt, and how omissions may be corrected without unnecessary interruption of care.

7. Audit retention and implementation. Please state the applicable retention periods and starting events for assessment versions, certification evidence, diagnostic signatures, authorization submissions, and electronic audit trails, including any different requirements for minors or records under audit or legal hold. Please publish the final policy, effective dates, training schedule, and transition instructions together, and identify which provisions remain draft until finalized.

Clear, consistent guidance across DMAS and managed care plans will help agencies budget for training and EHR changes, assign clinical responsibilities, and reduce avoidable authorization delays and claim denials.

Tiffany Robinson
Just N Time

HopeLink thanks DMAS for the opportunity to provide comments on this draft policy.

3.1 Needs Domains Rating Scale 

• The requirement that “a rating of 2 or 3 on most indicators signals a need the ISP shall address” is in direct contrast to the concept of client choice. It is unethical and inefficient to require that an ISP address any needs categories. This requirement also opens the possibility that the ISP will need to address a high number of needs categories, which is in contrast to a general best practice that treatment plans focus on a low number of specific and targeted goals.
  • REQUEST: It is requested that this language be amended to encourage but not require addressing of any service-relevant rating of 2 or 3 in an ISP.

3.4 Conditional Modules

• It is unclear whether and how the safety plan, required whenever Suicide Risk or Danger to Others is a 2 or 3, is different from the Crisis Mitigation Plan that is required for all participants of the redesigned services. If the plans are separate and distinct, and both required for high-risk clients, this seems confusing for both providers and clients, who will have two similar but separate plans to review, follow, and update.
  • REQUEST: Please clarify whether the safety plan can be used in place of the Crisis Mitigation Plan for high-risk members. If the documents are meant to be separate and distinct, please clarify how the two are meaningfully different and why both are clinically necessary.

3.4.2 Optional Modules

• REQUEST: Can you please clarify why these modules are not being required at launch, but will be required later?

4.3 Annual CANS Recertification

• The process for initial certification is described in 4.2, but 4.3 does not explain how to obtain annual recertification. Is it the same training and reliability test every year?
  • REQUEST: Please clarify how annual re-certification is obtained.

5.1.1.A The CANS Follows the Individual

• REQUEST: Please clarify how the MCO or DMAS “designates the lead provider” when an individual does not receive CPST or CSC; what is the decision-making process for this?

5.1.2 Periodic Updates

• There is no information, in this section or in other sections where the periodic update concept is discussed, about what documentation is required to meet this requirement, or what level of review. There is no information about credentials for providing the periodic update (can this be done by a QMHP, for example?) or what the nature of the “update” is (for example, is a face-to-face meeting required?).
  • REQUEST: Please provide more information on the nature of the periodic update, including documentation, credential, and service requirements.

5.1.4 Event-Based Reassessment

• REQUEST: Please clarify what happens in instances where a qualifying event occurs, but the reassessment is not able to be completed in the required timeframe (for example, an individual experiences a hospitalization, but remains symptomatic upon discharge and is unwilling or unable to meet with provider until 35 days after discharge; or an MCO takes several days to issue an authorization that comes after the 30 day mark).

6.2 Timeliness of Documentation

• It is not uncommon for individuals who are highly symptomatic to require assessment to be spread out over more than 1 day.
  • REQUEST: For assessments that require more than 1 day, please clarify whether the “5 business days” clock starts from the first assessment day, or the last.

6.3 Electronic Documentation Systems

• REQUEST: Please clarify the following:
  • How the electronic system will be accessed
  • Whether client consent will be needed for providers to upload their records, or to access their records when completed by another agency
  • Whether the electronic system will be able to “talk” to EHRs (ability to upload assessment straight from the EHR)
  • While the electronic system is being built: where the CANS data and spreadsheet will live, who it will be monitored by, and how it will be accessed by providers
    • Or, alternately, if this information is meant to be monitored internally among agencies only, until the electronic system goes live: how to determine whether an individual already has a CANS on file (in cases where individuals and their supports are not reliable reporters)

7.3.3 Event-Based Reassessment Service Authorization Process

• REQUEST: Please specify whether it is permitted to submit an authorization request in anticipation of a qualifying event: for example, an individual is hospitalized. Do we need to wait until they are discharged to submit the auth request, or could a request be submitted so that the authorization is obtained and a reassessment is able to be done ASAP upon discharge and minimizing barriers to re-engagement in treatment?

7.4 Coordination with Managed Care Organizations

• We would like to again mention, as we have in previous public comments on other services, the ongoing difficulty providers face in communicating with MCO care coordinators. Some MCOs provide an easier process than others, but the process for identifying and reaching the care coordinator is inconsistent across MCOs and an extraordinary amount of time can be spent just trying to obtain the contact information for the care coordinator.
  • REQUEST: It is requested that DMAS work with MCOs to develop a uniform and improved process for providing providers with the contact information for the MCO care coordinator.
  • REQUEST: It is also suggested that an improved process for internal communication within the MCO be developed, so that the provider is not relied on to communicate information that happens within the MCO. For example, an MCO care coordinator should be able to know when an event-based reassessment has been authorized by that MCO, instead of relying on the provider to inform them. An MCO care coordinator should also have access to the electronic documentation system that houses the CANS-Lifetime assessments and should have a degree of responsibility for keeping themselves informed of the information they need, rather than reliance on the provider.

9.1 Provider Quality Assurance Responsibilities

• This level of oversight by DMAS about quality control seems excessive and is novel. This is not a policy that exists in any current regulations for the provision of community mental health services or the related assessment.
  • REQUEST: Consider leaving these requirements to the agency to determine and allow the requirements to be naturally fulfilled through the other requirements already established in other sections (for example, the annual recertification requirement for providers to do the CANS was already established in an earlier section; allow the agency to determine its method for ensuring this).

A.2 Levels of Need Model and Service Array

• The requirement at each level of need that states that individuals must be screened for specific other services (for example, “A.2.4, “Individuals at LON 4 must be screened for eligibility for Functional Family Therapy, Coordinated Specialty Care, and Assertive Community Treatment”) is understood. While the criteria for some of these services are clear and distinct (such as age and diagnostic requirements for CSC), others- such as many of the functional impairment criteria for ACT- overlap significantly with those for CPST. It is not clear from these regulations how the provider, and consequently how the MCO, is to determine that an individual is “more appropriate” for one service over another in instances where that determination is somewhat subjective. An assessing provider could make a strong clinical argument for placing an individual in CPST over ACT, but a reviewing MCO could disagree and the authorization could be denied, resulting in an individual not receiving needed and/or timely services.
  • REQUEST: Please provide more clarification about how individuals should be assessed for alternate services, how this should be documented, and clearer criteria for “choosing” one service over another in instances where the decision is somewhat subjective.

In general, the CANS Lifetime reads as an assessment for children.  Some clinical staff may have difficulty administering to adults especially if they have limited exposure to working with children.  It will be difficult for one assessment to accurately assess across the lifespan.  

I'm additionally concerned at some of the ratings which suggest immediate action is needed. For example, what if a person has uncontrolled and/or untreated diabetes.  The individual has free will, but we have an assessment dictating immediate action needed.  What if the person refuses?  This assessment is said to guide treatment planning, but where does the individuals voice and choice fit in.  Similarly, what if a person is homeless, but has no income?  Many of our rural areas do not have shelters or day programs.   Sadly, there is often no immediate action that can be taken.   Who assumes this liability if immediate action is not or cannot be taken. 

How are CSB's expected to manage Same Day Access and implement an assessment such as this?  Not only is this burdensome for an assessor. It creates a barrier to accessing services for individuals with some of the highest needs. Already our assessment process is overwhelming to the individuals we serve. Adding an additional, time-consuming step is disappointing to say the least.  Furthermore, many of our agencies are short staffed. This will further limit our capacity to assist those in need.  

I assume that each program will have policy regarding how often the CANS Lifetime is administered.  How often is it expected to be administered per the guidelines or suggestions of those who developed it? 

Southside Behavioral Health (SBH) appreciates the opportunity to comment on the proposed CANS Lifetime assessment policy. As a rural Community Services Board, we are concerned about the staffing, technology, and funding needed to implement these requirements while maintaining timely access to care. We request clarification and practical implementation support in the following areas.

1. Training availability, cost, and implementation time

SBH needs sufficient time to plan for training, arrange staff coverage, and complete certification before the requirements take effect. Please clarify:

• When initial training and certification will become available.
• The cost of initial training, certification, and annual recertification.
• Which staff must be certified, including assessors, supervisors, and clinicians who review or sign assessment components.
• Whether DMAS will fund training or provide it at no cost to agencies.
• How much time agencies will have to train staff after the final policy and training resources are released.

Requested action: Publish a coordinated training and implementation schedule, including costs and certification requirements. Allow a reasonable preparation period after final guidance and training become available.

2. Identifying existing assessments and coordinating with MCOs

The expectation that the CANS follows the individual depends on providers being able to determine whether an assessment already exists and obtain the current version. Communication between CSBs and MCOs can be difficult, and identifying the appropriate care coordinator or contact often requires substantial staff time.

Please clarify how an agency will:

• Determine whether another provider has completed a CANS.
• Obtain the current assessment, including before a shared electronic system is available.
• Identify the lead provider responsible for updates and reassessments.
• Address situations in which the existing assessment cannot be located or obtained promptly.
• Meet assessment and authorization deadlines when another provider or MCO has not responded.

Requested action: Establish a consistent process for locating and sharing assessments. Provide a regularly updated directory of direct MCO and fee-for-service contacts, with an escalation process when providers cannot obtain a response. Delays outside the agency’s control should not interrupt needed services.

3. Electronic documentation and EHR integration

The electronic documentation requirements are unclear. In particular, agencies need a clear definition of a “DMAS-approved electronic documentation system.” It is difficult to plan staffing, workflows, vendor changes, and costs without knowing whether this means an agency’s existing EHR, a separate state platform, or both.

Please clarify:

• Which systems qualify and whether an agency’s existing EHR must undergo an approval process.
• Whether agencies may build the required assessment into their existing EHR rather than reproduce a separate template.
• Whether information must also be entered into a separate DMAS system.
• How assessments will transfer between EHRs, the state system, MCOs, and other providers.
• What consent, access, security, and electronic signature requirements will apply.
• What process agencies should use until the required electronic system is operational.

Requested action: Design the process to support one-time documentation and electronic sharing, with minimal duplicate entry. Release final technical specifications early enough for EHR vendors and agencies to build, test, and implement the necessary changes. Identify any associated costs and available funding.

4. Quality assurance requirements and inter-rater reliability monitoring

The proposed quality assurance requirements would create additional, unfunded responsibilities for SBH’s small Quality and Compliance Department. These duties would require staff time that is already committed to existing licensing, payer, audit, and agency oversight requirements.

The requirement for regular inter-rater reliability monitoring does not clearly explain the expected method or frequency. Please specify:

• How often monitoring must occur and how many assessments or staff must be included.
• Who is qualified to conduct the review.
• Whether monitoring may be completed through case vignettes, joint scoring, observation, or review of existing assessment information.
• What scoring standard is required and what corrective action is expected when raters disagree.
• What documentation agencies must retain to demonstrate compliance.
• Whether annual certification or recertification can satisfy any portion of this requirement.

SBH is particularly concerned about any expectation that an individual complete the assessment twice solely to measure staff reliability. These assessments require substantial time and participation. Repeating the interview could create an unnecessary burden for individuals and families, particularly those experiencing significant symptoms or difficulty remaining engaged.

Requested action: Provide a standardized, proportionate monitoring process that does not require duplicate client interviews. Supply sample tools, clear scoring standards, and technical assistance. Allow agencies flexibility to incorporate monitoring into existing quality assurance processes and identify funding to support the additional workload.

SBH requests that these issues be resolved before implementation, with sufficient time and resources for agencies to prepare. Clear requirements, reliable information sharing, and practical oversight methods will help agencies implement the assessment consistently while preserving staff capacity and access to services.

The Virginia Association of Community-Based Providers (VACBP) thanks DMAS for the opportunity to comment on the draft CANS Lifetime Policy Appendix. These comments reflect input from VACBP's Member's Advisory Council.

We support a single standardized assessment that follows the individual, the phased rollout of conditional modules, and the appendix's emphasis on trauma-informed, culturally responsive, family-involved assessment.

1. ADD AN EFFECTIVE DATE AND TRANSITION RULES

The appendix has no effective date and does not address the Comprehensive Needs Assessment (CNA). Please:
- State the date the CANS Lifetime becomes required. Confirm that the CNA remains valid until then, including for new CPST and CSC admissions.
- Clarify whether MH-IOP, MH-PHP, ACT, MST, FFT, and Clubhouse will require the CANS Lifetime. Attachments A and B include these services, but Section 1.2 does not.
- Resolve the H0031 overlap. H0031 is currently the IIH assessment code, and this appendix limits H0031 to one per individual per calendar year.

2. PUBLISH THE LEVEL OF NEED ALGORITHM AT LEAST SIX MONTHS IN ADVANCE, AND KEEP CLINICAL JUDGMENT CENTRAL

The scoring algorithm will directly inform service tiers, staffing models, compensation, and financial projections, so it is foundational to the entire CPST restructuring. Providers need time to evaluate their existing populations, develop financially sustainable operating models, and implement the workforce and operational changes that follow. A 90-day window would not be sufficient. Please:
- Publish the final algorithm, the interim spreadsheet, and practice cases no less than six months before the CANS Lifetime is required.
- Confirm that the algorithm is decision support only (Section 7.1). CANS ratings involve real clinical judgment, and certified clinicians can reasonably rate the same need differently.
- Require MCO reviewers to be qualified, CANS-certified behavioral health clinicians.
- Do not allow a reviewer to change a rating without a peer-to-peer review with the assessing clinician.

3. FUND CERTIFICATION AND PUBLISH A TRAINING PLAN

An agency may need to certify dozens of staff every year. Please:
- Confirm that initial training and annual recertification will be provided at no cost to providers, and publish the timeline.
- Name the certification contact (Section 10.2).
- Allow a short grace period for renewals.
- Publish a single calendar of all Behavioral Health Redesign training requirements, since these requirements are accumulating for providers.

4. MAKE EVENT-BASED REASSESSMENTS NOTIFICATION-ONLY

If prior authorization is retained, please allow retroactive approval and pause the 30-day timeframe while the request is pending (Sections 5.1.4 and 7.3.3).

5. CLARIFY BILLING ACROSS PROVIDERS

Please:
- Explain billing when an individual changes lead providers mid-year, or already has an authorization with another provider.
- Confirm that periodic-update work is reflected in service rates.
- Publish the H0031 rate.

6. PROVIDE CONSENT GUIDANCE AND PROTECT AGAINST MISREADING CHANGES IN THE LEVEL OF NEED

Please:
- Explain what happens when a member does not want their CANS shared.
- Explain how sharing fits within treatment, payment, and operations rules and 42 CFR Part 2 for the SUD module.
- Provide a standard release.
- State that a higher Level of Need on reassessment, which often reflects new disclosure as trust develops, is not by itself evidence that a service has failed.

7. STANDARDIZE MCO REQUIREMENTS

Please establish one set of submission requirements, forms, and turnaround times for all MCOs and fee-for-service, and publish direct MCO contact information (Section 7.4).

8. USE CORRECTIVE ACTION INSTEAD OF RECOUPMENT DURING START-UP

For the first 12 months, please address good-faith documentation errors through technical assistance and corrective action plans rather than recoupment (Section 9.3).

9. CLARIFY WHO SETS THE AUTHORIZED LEVEL OF NEED

Please clarify that the provider recommends and the MCO or Acentra authorizes. Require that a properly documented deviation be honored, or that any denial be explained in writing (Attachment A, Section A.3).

10. INTERPRETER ACCESS AND NEUTRAL LANGUAGE

Please:
- Explain how the qualified interpreters required by Section 5.2.3 will be funded and located.
- Replace "treatment based on financial interest of providers" in Section A.1(6) with neutral language about matching service intensity to need.

11. TECHNICAL CORRECTIONS

- Section 3.4: replace the "Section [X]" placeholder.
- Section 4.3: correct "ADMAS."
- Section 4.4: complete the VAC reference placeholder, and reconcile "elements 14 and 15" with Section 6.1, where diagnosis and formulation are numbered 13 and 14.
- Sections 7.3.2 and 7.3.3: correct the step numbering.
- Section A.1: the reference to "A.4" should be A.3.
- Use "Safety Plan" and "Crisis Mitigation Plan" consistently (Sections 3.3, 3.4, 6.1, 8.4, 11.2), or define how they differ.
- Section 11.2: reconcile "signed and dated by the certified LMHP" with Section 4.4, which allows a certified QMHP to complete the ratings.

VACBP appreciates DMAS's work on this appendix and is glad to support provider readiness and training outreach.

The Virginia Association of Community Services Boards (VACSB) appreciates the opportunity to provide feedback on the proposed CANS Lifetime Assessment. VACSB supports efforts to promote consistent, person-centered assessments and improve coordination of care. However, several areas of the proposed policy require clarification or revision to ensure consistent implementation, minimize administrative burden, and avoid unnecessary barriers to accessing services.

1. Limit Initial Implementation to CPST and Coordinated Specialty Care

VACSB strongly recommends that DMAS limit the initial implementation and required use of the CANS Lifetime Assessment to Community Psychiatric Support and Treatment (CPST) and Coordinated Specialty Care (CSC), rather than applying the requirement broadly across Medicaid behavioral health services.

Section 1.2 of the proposed policy states that it applies to all Medicaid-enrolled behavioral health providers, "including but not limited to" CPST and CSC. Section 5.1.1 further indicates that a comprehensive CANS is required when an individual first accesses Medicaid behavioral health services or does not have a current valid assessment on file. This language creates uncertainty regarding whether the assessment is required only for designated services or more broadly across Medicaid behavioral health services.

Requiring a comprehensive CANS for individuals entering any Medicaid behavioral health service would create a significant administrative burden for CSBs, strain already limited workforce capacity, and potentially delay access to needed services. The operational requirements associated with completing, maintaining, and updating these assessments across multiple programs and providers would be substantial.

A phased implementation, initially limited to CPST and CSC, would allow DMAS and providers to evaluate assessment workflows, staffing requirements, information-sharing capabilities, and the impact on service delivery before considering expansion to additional behavioral health services.

VACSB requests that DMAS explicitly limit the initial requirement to complete and maintain the CANS Lifetime to individuals receiving CPST or CSC. The policy should clarify that the CANS is not a universal intake requirement for individuals accessing other Medicaid behavioral health services and that referring providers are not responsible for completing the assessment solely because they initiate a referral.

2. Assessment Responsibility and Coordination

While Section 5.1.1.A establishes a hierarchy for designating a lead provider responsible for maintaining the CANS Lifetime and addresses transfers of responsibility when services end, additional operational guidance is needed to ensure consistent coordination across programs and providers.

DMAS should clarify how the responsibilities of the designated CANS lead provider align with the care coordination and transition responsibilities outlined in the Member Transition Plan, particularly when individuals receive services from multiple providers.

Additional guidance should establish procedures for notifying and acknowledging transfers of assessment responsibility, ensuring receiving providers have timely access to the existing assessment, and identifying who assumes responsibility when the designated lead provider or qualified assessor becomes unavailable. The policy should also clarify the process for designating or reassigning responsibility when service arrangements change and the established hierarchy does not clearly identify a lead provider.

These procedures should ensure that receiving providers can rely on an existing valid assessment without unnecessary duplication or disruption in services.

3. Assessment Access and Information Sharing

VACSB requests additional guidance regarding where CANS Lifetime assessments will be maintained, which providers and staff will have access, and how information will be shared across agencies and managed care organizations.

Although Section 5.1.1.A directs receiving providers to use an existing valid assessment, and Section 6.3 outlines the initial use of a documentation template and spreadsheet while an electronic system is developed, the process for locating, accessing, and transferring assessments requires further clarification.

DMAS should establish a consistent process for verifying whether a current assessment exists and ensuring timely access when individuals transition between providers or programs.

As DMAS develops the electronic CANS system described in Section 6.3, VACSB recommends incorporating functionality to track periodic updates and annual reassessment deadlines and notify responsible providers when assessments are due. Because the CANS follows the individual rather than the agency, this functionality would be particularly important when individuals receive services from multiple providers or transition between programs.

DMAS should also provide guidance on how providers are expected to track these requirements during the initial implementation period before the electronic system becomes available.

4. Reassessment Requirements and Service Authorization

Sections 5.1.2 through 5.1.4 establish periodic updates, annual comprehensive reassessments, and qualifying events and timeframes for event-based reassessments. Section 7.3.1 also distinguishes which assessment types require separate service authorization.

However, additional guidance is needed regarding how these requirements interact in practice, particularly when an event-based reassessment occurs near a scheduled periodic update or annual reassessment. DMAS should clarify whether an event-based reassessment resets or otherwise affects subsequent assessment deadlines and how overlapping requirements should be documented and billed.

Additionally, Sections 7.2.1 and 7.3.1 describe authorization as required before billing for an event-based reassessment, while Section 7.3.3 requires providers to obtain approval before completing the reassessment. These provisions should be reconciled to clearly establish whether authorization must be obtained before the assessment is performed or before the claim is submitted.

Because Section 5.1.4 establishes specific deadlines for completing event-based reassessments, DMAS should also clarify how providers are expected to meet these deadlines when authorization is delayed, including whether extensions or exceptions will be permitted.

While Section 7.3.3 provides that underlying services continue under their existing authorization when an event-based reassessment request is denied, additional guidance is needed regarding whether the reassessment must still be completed and how providers should proceed in those circumstances.

VACSB recommends practical examples illustrating how assessment timelines, authorization requirements, and billing procedures interact to promote consistent implementation and prevent disruptions in care.

5. Documentation, Ratings, and Treatment Planning

The draft recognizes that individuals and families may decline to discuss certain topics and that providers must document unavailable information. However, additional guidance is needed to ensure consistent documentation and interpretation of assessment ratings.

Specifically, DMAS should establish a clear method for distinguishing information that could not be obtained, declined responses, and nonapplicable items from needs or strengths that have been assessed and determined to be absent. This is particularly important for the Strengths Domain, where Section 3.2 permits a rating of 3 when information remains unavailable after reasonable efforts.

Additionally, Section 3.1 identifies ratings of 2 or 3 as actionable needs that generally must be addressed in the Individual Service Plan (ISP). For individuals with multiple complex needs, addressing every actionable indicator simultaneously may not be clinically appropriate or realistic.

Although the documentation template references prioritized actionable items, DMAS should clarify throughout the policy and supporting materials that treatment planning may prioritize identified needs based on clinical judgment, safety, individual and family preferences, and available resources. Guidance should explain how providers document actionable needs that cannot reasonably be addressed simultaneously.

6. Age-Specific Requirements and Assessment Modules

VACSB recommends that DMAS develop a consolidated age- and circumstance-based crosswalk identifying applicable assessment domains, required and optional modules, and caregiver participation requirements.

While the draft identifies caregiver interview requirements and distinguishes modules required at launch from those that will become mandatory later, consolidating this information would support consistent administration and reduce the potential for errors.

DMAS should also reconcile inconsistencies across the policy, documentation template, and reference guide. For example, the documentation template places Independent Living Skills under the "Ages 6+" heading, while Section 8.1 of the policy and the reference guide identify Independent Living Skills as applicable beginning at age 14. The template should be revised to reflect the age 14 threshold.

Similarly, Section 3.4.2 identifies the Justice/Crime Module as optional during initial implementation, while Section 6.1 describes it as required when actionable. These provisions should be reconciled so providers clearly understand which modules are mandatory at launch and which will become required later.

Additionally, the policy should reinforce the importance of developmental considerations when assigning ratings, particularly for young children. For example, guidance addressing Oppositional Behavior should distinguish developmentally typical behaviors from clinically significant concerns. Although the draft recognizes developmental context, practical examples would assist assessors in applying ratings consistently.

VACSB also recommends incorporating clear reminders in the reference guide and documentation template that, while ratings generally reflect the preceding 30 days, certain indicators require consideration of different timeframes or relevant history.

Sections 3.3 and 5.2.2 already recognize exceptions to the standard 30-day window. However, the compliance checklist in Section 11.2 should be revised to explicitly acknowledge these exceptions rather than suggesting uniform application of the 30-day window across all indicators.

7. Provider Qualifications, Signatures, and Billing

VACSB requests that DMAS reconcile the requirements governing who may complete, sign, co-sign, and bill for the CANS Lifetime Assessment.

Section 4.4 permits a certified Qualified Mental Health Professional (QMHP) to complete CANS ratings and establishes additional requirements for diagnostic formulation and signatures when the assessor cannot independently diagnose. However, Section 11.2 indicates that the assessment must be signed by a certified Licensed Mental Health Professional (LMHP), creating uncertainty regarding the signature requirements for assessments completed by QMHPs and other qualified practitioners.

Section 6.1 and the documentation template also establish signature and certification requirements that should be reconciled with these provisions.

VACSB recommends that DMAS provide a credential-based workflow identifying who may complete the assessment, render and sign the diagnosis and clinical formulation, provide supervisory co-signatures when applicable, and support billing for the assessment.

This guidance should clearly distinguish the responsibilities of certified QMHPs, independently licensed LMHPs, and LMHPs practicing under supervision, consistent with applicable Medicaid regulations.

DMAS should also reconcile the documentation element references in Section 4.4 with the numbered documentation requirements in Section 6.1 to ensure that the diagnosis and clinical formulation requirements are consistently identified.

Ensuring consistency across these requirements would reduce confusion, support compliance, and prevent unnecessary delays in assessment completion and reimbursement.

8. Level of Need Determinations

Attachment A establishes the Level of Need (LON) framework and provides guidance for documenting deviations from the recommended Level of Need. However, additional information is needed regarding the methodology used to calculate the recommended level and how it informs authorization decisions.

Section 6.3 indicates that DMAS will initially use a spreadsheet to determine the Level of Need while the electronic system is developed. VACSB recommends that DMAS provide the methodology used by this spreadsheet, including the indicators, scoring criteria, and applicable decision rules used to generate the recommended Level of Need.

This information, along with practical examples, should be available to providers before implementation to ensure transparency and consistent application.

Additionally, while Attachment A establishes documentation requirements when the authorized Level of Need differs from the recommended level, practical examples would help providers understand how to support clinically justified deviations.

DMAS should also clarify the distinction between the provider's determination of the appropriate Level of Need and the authorization decision made by the MCO or DMAS service authorization contractor, including how disagreements or differing determinations should be documented and resolved.

Clear guidance will help ensure consistent application of the Level of Need model and support appropriate access to medically necessary services.

VACSB appreciates DMAS's consideration of these recommendations. Limiting initial implementation to CPST and CSC, accompanied by clear and consistent guidance regarding provider responsibilities, information sharing, reassessment timelines, documentation requirements, and service authorization, would support a more manageable and effective implementation while protecting timely access to behavioral health services.

 I am providing feedback again today, on the draft CPST regulations and the related assessment instrument – the CANS Lifetime. Overall questions and concerns in regard to CPST implementation and potential negative impact remain. Significant concerns continue to be expressed by Child & Family service providers who have had long-standing experience with administering the CANS as related to CSA-funded services.

Now that a draft version of the CANS Lifetime has been released, when will data regarding validity & reliability measures for this instrument be publicly provided?

When can providers anticipate a state-wide Training Plan to be rolled out?

Will there be affiliated costs and if so, what will those costs entail – one-time training & certification versus annual recertification & subscription?

It is indicated that the ‘CANS will follow the individual’; as such, will there be a state-wide CANS repository … or will current providers be expected to navigate releases of information and obtain the prior CANS from the former provider?

If there is some sort of database, how will individuals’ confidentiality be protected?

Respectfully Submitted,

Paulette Skapars

Thank you for the opportunity to provide feedback on the proposed CANS Lifetime. We feel that several provisions raise some operational, clinical, and administrative concerns for Community Services Boards (CSBs) and other providers.

Navigating the Canvas system and Okta presents significant challenges for staff. Users are automatically locked out if they do not access the system within 30 days, and staff frequently experience additional access and authentication issues. These barriers have the potential to delay completion of required assessments and create unnecessary administrative burden.

The draft also states that supervisors who co-sign CANS assessments must maintain CANS certification. This creates an ongoing requirement for supervisory staff and may present challenges. Obtaining and maintaining certification is not a simple process, and many staff require multiple attempts to pass the certification examination. Requiring certification for both assessors and supervising staff increases training demands.

The requirement to obtain completed CANS from another provider or the MCO may also create delays in service initiation. Coordinating receipt of assessments from external entities will add administrative burden and slow access to needed services.

The draft references required quarterly updates but do not clearly define the scope of these updates and without guidance, providers will implement requirements inconsistently.  Additional clarification is needed regarding specific information that must be reviewed or updated, if updates require a formal reassessment of CANS domains, documentation standards that apply and expected time and effort.

The definition of "qualifying events" appears broad and could result in a significant increase in reassessments. For example, trauma disclosure is identified as a qualifying event requiring reassessment. Given the varying definitions and interpretations of trauma across providers and agencies, determining when a disclosure meets the threshold for reassessment may be challenging and could lead to inconsistent implementation and a substantial increase in the number of CANS assessments completed.

The proposed assessment schedule establishes recurring updates every six months for adults, annual comprehensive reassessments, and additional reassessments triggered by qualifying events. While reassessment is important when circumstances change, these requirements create a substantial ongoing workload. Completing a meaningful assessment involves far more than entering ratings into a standardized instrument. It may require clinical interviews, review of medical and behavioral health records, consultation with family members or other providers when appropriate, evaluation of functioning across multiple life domains, documentation of supporting evidence, and integration of findings into an individualized service plan. For CSBs, these responsibilities compete directly with clinician time available for treatment, rehabilitation, crisis intervention, care coordination, and other community-based services.

There are specific concerns regarding Section 5.1.4, which establishes mandatory event-based reassessment requirements following a broad range of clinical, personal, and service-related events. While significant changes in an individual's circumstances may warrant reassessment, the policy requires comprehensive reassessments within specified timeframes for events that vary considerably in their clinical significance and implications for treatment The proposed triggers include psychiatric hospitalization or crisis stabilization discharge, significant clinical improvement or deterioration, new trauma disclosures, changes in household composition, transitions into or out of the justice system, and gaps in services exceeding 90 days. Most of these events require reassessment within 30 days.

For CSBs, these requirements create substantial operational challenges. Such events frequently occur without advance notice and may affect multiple individuals on a provider's caseload within a short period. Completing a comprehensive reassessment requires clinician time, record review, interviews, collateral contacts, clinical formulation, and detailed documentation. These responsibilities must be met while CSB staff continue to provide treatment, crisis intervention, care coordination, and other essential community-based services.

The policy does not distinguish between an event that requires an immediate clinical response and an event that necessarily requires a complete reassessment of every CANS domain. For example, a new trauma disclosure may warrant sensitive therapeutic support and a targeted safety assessment without necessarily changing the individual's overall service needs. A change in household composition may or may not have a meaningful effect on clinical functioning. Similarly, improvement in symptoms may reflect successful treatment rather than a need to initiate another comprehensive assessment.

There is concern about the interaction between these mandatory deadlines and the reimbursement provisions. Section 7.2.1 requires event-based reassessments to be billed under H0031 with the U1 modifier and requires service authorization before billing. This creates a potential conflict between the obligation to complete a reassessment within the specified timeframe and the uncertainty of obtaining timely authorization and reimbursement.

The draft references interim tools for documenting assessments and calculating Levels of Need while longer-term electronic infrastructure is developed. It also indicates that service-planning algorithms and additional requirements will be implemented in future phases. This phased approach raises concerns regarding readiness, operational consistency, staff training requirements, and the ability of providers to implement requirements effectively while key infrastructure and processes remain under development.

As many other comments have stated, the transition to the CANS Lifetime assessment presents significant concerns, challenges, and anticipated barriers ranging from removal of person-centered care to the elimination of client privacy. This writer is in agreement with points provided by other commenters, including:

• Leslie Sharpe, NRVCS
• Paulette Skapars
• VACSB
• Virginia Association of Community Based Providers
• Nicole Lewis, Southside Behavioral Health
• Emily Hollidge, HopeLink Behavioral Health
• Tiffany Robinson, Just N Time

For reference throughout, additional specific points under headers have been added to the end of the numerical point. For example, 9.1, #3, is listed as 9.1.3.

To begin, there are portions of the Appendix (TBD): Comprehensive Assessment of Needs and Strengths (CANS Lifetime) that are appreciated. Those specific points include:

• 5.1.3.2 – Allowing for one periodic review (of the required 4) to be replaced by the CANS Lifetime reassessment.
• 5.2.3.1 – The emphasis on qualified human interpretation as a requirement in place of machine/electronic translation
• 5.5 – This section provides a clear explanation and expectation for family and individual involvement.
• Section 11 – The checklists presented are very helpful for basic overview

Overall Concerns

This manual opens with “This Medicaid Provider Policy Manual establishes the requirements, standards, and procedures governing the use of the Virginia Comprehensive Assessment of Needs and Strengths (CANS) Lifetime 1.0 as a condition of Medicaid reimbursement for behavioral health services in the Commonwealth of Virginia…. This policy applies to all Medicaid-enrolled behavioral health providers, including but not limited to: 1. Community Psychiatric Support and Treatment (CPST) 2. Coordinated Specialty Care (CSC).” Throughout the manual, there are numerous references to the CANS Lifetime assessment being required for all Medicaid reimbursed behavioral health services, which an excessive burden that will create more of a barrier to services than any possible assistance it is currently seeking to provide.

Section 3

Will an option of “Not Applicable” be available for sections that do not apply to individuals, such as Independent Living Skills for younger clients?

3.1 – The statement that a rating of 2-3 “signals a need the ISP should address” directly opposing the idea of client choice and person-centered care and documentation. This suggestion or requirement will lead to formulaic and non-person-centered documentation and ISPs. Alternatively, the idea that this will require additional documentation to support not including this item in the ISP based on client choice will create an unnecessary burden on providers with the additional of all requested documentation.

3.3 – Please provide clarification and guidance on the listed “Crisis Mitigation Plan,” as it is unclear if this will be an item included within the assessment or if safety plans (or specified safety plans from 3.4) will be required.

3.4.1 – An explanation for the selection of modules required at launch as opposed to those elected as optional at launch would be insightful and helpful to assessors and the public at large. There are concerns regarding the lack of include of Sexual Aggression in the initial required modules due to the significant impact of these behaviors on others.

Section 4

4.4 – technical error on page 9 “[add VAC or manual references]”

Section 5

Please specify if event-based reassessments will reset the annual date for future assessments.

5.1.1 – Please clarify if the CANS Lifetime assessment is for all Medicaid reimbursement for behavioral health services or just those requiring a CANS-based authorization. If the CANS Lifetime assessment becomes the expectation for all Medicaid reimbursed behavioral health services, the administrative burden this places on providers will drastically impede their ability to provide services, increase workload to an excessive level, and impact services that are available to individuals and families. The barrier this creates alone during Same-Day Access would be prohibitive for families and providers.

5.1.1.A – What is the intended location for the CANS assessments verification and what will the verification process be for determining if a CANS assessment exists within the calendar year for an individual? Currently, accessing this information through MCOs requires extensive wait time and will impact a CSBs ability to complete all necessary activities related to Same-Day Access and connection with services.

5.1.2 – Is the term ‘youth’ used for all individuals under 18 years old? Some standardized measures incorporate individuals as young as 15 in adult measures.

5.1.4 – Please provide guidance regarding if services will still be able to be provided and reimbursed while awaiting the response to an event-based reassessment.

Who will be responsible for determining if an event is “worthy” of being reimbursable? Is the appeal process going to be expedited due to the limited timeframe offered for reassessments? Is the expectation that if an event is determined by the provider to necessitate an event-based reassessment, is the expectation that a reassessment still occur even if denied for reimbursement? Additionally, In instances where trauma in not disclosed in an initial assessment however is subsequently disclosed in a later session with provider, what period of time must have elapsed before an event-based reassessment becomes ‘valid’? (Also see 6.4)

5.2.2 – The explanation provided does not rationally make sense with the example given related to behaviors. The 30 day window is determined to be “the preceding 30 days,” and the example given lists “individual who has not engaged in self-injurious behavior in 28 days… shall still be rated at an actionable level.” Please provide an alternative example to more readily highlight the intended point that underlying risk factors that are present warrant an actionable rating regardless of if the associated behavior has occurred within or outside of the preceding 30 days.

5.5 – The “shared vision” the CANS is intended to represent seems to be vision of the draft authors and original proponents of implementing the CANS lifetime assessment as opposed to the vision of individuals and families. This is based upon the numerous references to requiring specific items be included in the ISP in place of person-centered care.

6.4 – Please provide guidance regarding the length of time that is permissible for amended or corrected CANS ratings, as well as what constitutes a correction or amendment for the purposes of this manual.

7.2.1 – Please clarify the accessibility of the electronic system and authorized users, as the ability to reference this system will have a dramatic impact on CSBs, particularly, with Same-Day Access. If an individual receives another CANS Lifetime assessment within the 5-day window to submit this information, how will this situation be handled as there way no assessment at the time of initial verification.

7.3.2.4 – Please provide guidance on anticipated turnaround and associated documentation required to submit for a “qualifying event” triggering a reassessment.

7.3.3, #3-4 – The request for an event-based reassessment requires documentation of the qualifying event, its clinical impact, and clinical rationale, which is essentially a request for a pre-assessment to determine if a reassessment is required. Additionally, as non-treatment providers are expected to review authorization requests, what is the impact of clients’ requesting to limit the amount of information provided within the request?

8.1.2 – Please clarify expectations for linking individuals to residential stability services given the limited availability of this support in many areas of the state.

8.1.3 – Please provide clarification on “willingness” and participation in taking prescribed medications.

8.3.2 – Please provide clarification and guidance on ratings for individuals with complex trauma.

8.6.1 – The commonality of multiple household involvement with youth almost necessitates a minimum of 2 Caregiver Resources and Needs sections for all assessments. For rating additional households, are individuals from each household required to be present for assessment, or is it to be completed based upon the report of another individual?

9.1.3 & 9.2.5 – Please provide clarification on how inter-rater reliability monitoring will be conducted.

9.1.4 – Please provide clarification on the expectations for clinical supervision as it relates to CANS completion.

9.4.5 – Please provide clarification and guidance regarding how a determination will be made regarding “the same narrative language across multiple clients,” as many providers have a consistent ‘voice’ when writing narrative portions of assessments.

Attachment A

The entirety of this attachment is primarily written for adults with minor additions as they relate to youth services, such as the requirement of a screening for Functional Family Therapy prior to being enrolled in any Level of Need 3 (or higher) services.

A.1.3 – This section states individuals should receive services that “…provide them a vision and path to recovery however that is defined for the individual,” which appears to contradict sections 7.3.2.4 and 3.1 which focus on prescriptive treatment for needs.

A.1.6 – This appears to be the underlying crux of the redesign, which has resulted in an overall of a state-wide system, based on the actions of a few, while disregarding the impact on the masses.

A.2 #3-6 – The requirement that a screening be completed for specific interventions directly opposes clients’ rights and choice. Additionally, please provide guidance regarding what a screening “prior to enrollment in other Level of Need [#] services.”

Attachment B

The unit ceiling identified for services directed at youth is a significant decrease in supportive services from currently available services under the 'legacy' system. The current unit ceiliing for Functional Family Therapy (which youth at Level 3 or higher should be screened for) has a current unit ceiling of 160 for a 5 month authorization, with a 15 minute unit duration, which equates to an average of 2 hours per week for an intensive service. 160 units/4=40 hours, 40 hours/5months = 8 hours per month. While the underlying goal of the redesign appears to decrease cost overall, the drastic decrease in support is more likely to require additional costs in the form of increased higher levels of care due to the absence of community-based support at previous levels.

2.1 & 4.4

Please provide additional clarification regarding if this is a combined assessment or not. Is the CANS Lifetime assessment expected to be completed by a single person or a team? There are multiple clarifying points regarding QMHP, LMHP-E, and LMHP assessors and their roles. Is this section intended to provide ways for a treatment team to work together, such as case managers and other providers, or is this primarily aimed at MCO-appointed lead providers later identified in  5.1.1.A, #2 & #3?

2.1 - indicates the CANS Lifetime assessment is “the combined assessment document of record” and later states “the CANS ratings and the mental health evaluation are not separate documents.”

4.4 – “A QMHP who holds current CANS certification may complete the CANS rating” however the mental health evaluation cannot be completed by a QMHP.

5.1.1 & 7.2.1

Please provide guidance regarding the anticipated location and accessibility of information pertaining to verifying if a CANS has been completed within the calendar year.

5.1.1.A – What is the intended location for the CANS assessments verification and what will the verification process be for determining if a CANS assessment exists within the calendar year for an individual? Currently, accessing this information through MCOs requires extensive wait time and will impact a CSBs ability to complete all necessary activities related to Same-Day Access and connection with services.

7.2.1 – Please provide guidance regarding the anticipated permissible turnaround times given to MCOs if this is the required verification process, as this will significantly impact the ability to initiate services for individuals.

5.1.4, 5.4.2, 6.4, & 7.2.1.4

5.1.4 & 7.2.1.4 – Please provide greater detailed guidance regarding if services will still be able to be provided and reimbursed while awaiting the response to an event-based reassessment.

Who will be responsible for determining if an event is “worthy” of being reimbursable?

Is the appeal process going to be expedited due to the limited timeframe offered for reassessments, or will there be an extension granted for acceptable timeframe?

Is the expectation that if an event is determined by the provider to necessitate an event-based reassessment, is the expectation that a reassessment still occur even if denied for reimbursement?

In instances where trauma in not disclosed in an initial assessment however is subsequently disclosed in a later session with provider, what period of time must have elapsed before an event-based reassessment becomes ‘valid’?

5.4.2 - Will a declination of discussion regarding trauma by the family ever be determined to require punitive action, such as if a provider has multiple back-to-back refusal that are documented?

6.4 – Please provide guidance regarding the length of time that is permissible for amended or corrected CANS ratings.  How long of a period of time is allowed for a retroactively modified CANS in situations such as these trauma disclosure after beginning services with provider?

Closing

Additional concerns exist related to the Level of Need algorithm which is currently undeveloped and the electronic documentation system for entering CANS information which is to be built following the implementation of the CANS Lifetime assessment requirements. When is the anticipated date for the DMAS algorithm to be finalized? Please provide additional information regarding the reliability and validity of this algorithm prior to launch of this redesign.

HAMHDS appreciates being provided the opportunity to make comments and seek clarification on the proposed CANS Lifetime Assessment. 

Good afternoon,

Thank you for the opportunity to respond to the CANS Lifetime Assessment Manual.

5.1.1A What happens if the CANS Lifetime is completed by another company and (a) we are unable to get the results (b) there is provider disagreement (c) what is the reimbursement for additional coordination of care (d)Why do children need CANS updates every three months while adults only need them every six months? What is the clinical justification for this. 

How much does it cost for providers to be certified and re-certified in CANS.

Will there be assistance for this as most staff will be required to be credentialed.

What is the reimbursement rate for the initial CANS?  It sounds like the subsequent periodic CANS will only be reimbursed through units/sessions however units are limited. Having this requirement every 3 months is an abundance of admin duties considering the other duties required by CPST (care coordination, crisis services, diagnostic assessment, Quarterly/ISP, etc.). This is especially true when we have to do a reassessment and full CANS in addition to a quarterly CANS.

Will quarterly updates change the client's LON? If so, will authorized services and units increase or decrease automatically, or will another assessment be required? The MCO continue to make approvals difficult, are inconsistent and accessing staff for appeals, expedited appeals and peer to peer reviews is cumbersome. How will that be streamlined to not create further admin duties?

If a client is improving because services are working, how will DMAS ensure those improvements don't result in services being reduced too soon?

What if services recommended by the recommended level of care are unavailable in areas?