Overview of the Clinical Care Review (CCR) process

This article provides an overview of the Clinical Care Review (CCR) process and answers some frequently asked questions. Note that currently, the CCR Process ONLY applies to therapists in California.

What is Clinical Care Review?

A Clinical Care Review (CCR) is a qualitative and quantitative review of documentation in a client’s record to determine if there is a clinical need for ongoing care.  You can read our CCR policy here.

Who completes the Clinical Care Review?

Rula employs licensed Clinical Care Reviewers who are members of the Quality Team.  Each reviewer has more than 5 years of clinical experience and has spent a minimum of 3 years engaged in peer review or utilization management. 

Which clients receive a Clinical Care Review?  

At present, the CCR process is only in place for clients covered by Kaiser SoCal. 

When does a Clinical Care Review take place?  

Reviews are completed prior to the 16th visit (typically after the 13th session) and then every 10 visits after that while a client is engaged in care (i.e., session #13, 23, 33, 43, etc.). 

Do I need to keep track of session counts?

No. The Clinical Care Review takes place automatically in the background of your practice. There is no need for therapists to count sessions or reach out to Rula to request a review.  There is no need for the client to count sessions or reach out to Kaiser to request additional care. 

Do clients have a limit to the number of sessions they can have through Rula?

No. Kaiser provides an initial outpatient therapy referral from the client’s PCP for up to 16 sessions. This is a very misleading referral for clients and therapists, as there is often a misperception that the client is limited to 16 sessions, which is incorrect! Clients may continue to receive care as long as documentation reflects a clinical need for treatment. 

What documentation is reviewed to determine the need for ongoing care?

The reviewer is evaluating the following aspects: 

  • DSM diagnosis with clearly documented symptoms
  • Moderate to severe symptom severity and the presence of associated functional impairments (i.e., symptom distress interferes with work, school, relationships or social functioning) 
  • Interventions are targeted to impact functional impairments, align with the current treatment plan, and are reflected in progress notes (i.e., the presence of the Golden Loop!)
  • Goals on the treatment plan are actively updated and being worked on,and align with the diagnosis and the progress notes
  • Outcome measure changes that indicate a need for ongoing care
  • Client is engaged in care as evidenced by regular attendance in appointments and completing therapeutic tasks 
  • Client is capable of developing skills to manage symptoms or make behavioral change
  • Client does not require a higher level of care (HLOC). For information about requesting HLOC support from our Care Coordination team, please see here

 Support for clinically indicated care is present when the following is reflected in clinical documentation:  

  • The service is directed towards reducing the effect of symptoms/behaviors of the diagnosis on record and its resulting functional impairments (i.e., explain how symptoms/behaviors are impairing the person’s life) or, 
  • The service is provided to prevent an increase in symptoms/behaviors or functional impairments (i.e., explain how services are provided to prevent deterioration or to maintain the current level of functioning)

Here are some of Rula’s reasons for determining clinical justification is not present:

  • Documentation reflects that the client has or is approaching achievement of their goals
  • The client requires a higher level of care
  • The purpose of care is not directly related to improving symptoms and/or functional impairment specified on the treatment plan
Note: If you’re not already discussing the outcome measures with your clients, we strongly recommend you introduce that into the relationship and to guide treatment planning. Details about the use of outcome measures in practice can be found in the Measurement-Informed Care section of the help center. We also recommend using the resources from the Sample Clinical Documentation Library to help address issues that were flagged in this client's chart.

How will I know if ongoing care has been deemed clinically indicated based on my documentation?

Your clinical work drives this decision based on what is documented in the client’s record.  If you don’t hear from Rula, continue to treat your client as needed. No news is good news! The Clinical Care Review process will repeat itself continuously in the background of your practice and will rely on your notes regarding the client’s needs and the treatment plan (as described above).  No action is needed.  

How will I know if ongoing care has NOT been deemed clinically indicated based on my documentation?

You'll be notified via email of this determination which will include 2 calls to action based on your recommendation:

1. Discharging this client based on our finding

If you’re recommending discharge/termination:

  • Please reference Rula’s Discharge Policy, linked here.
  • The email notification will include aftercare resources to review with your client.
  • If your client presents new issues/problems/goals during your termination (i.e., requires additional care and you are recommending continued treatment) discussion, please proceed with the 2nd option of completing the clinical review update. 
  • If your client wants to return to treatment past 30 days of their last session/completed CCR, they will need to request a new referral from Kaiser.  

2.  OR Complete Clinical Review Update note in AMD. 

  • If you’re recommending ongoing care, please read through and complete all listed steps in the next section below. 

What if I’m recommending that my client receive ongoing care?

If you’re recommending ongoing care for your client, even if it’s just for a few sessions to appropriately discharge, please complete the following steps before your client’s next appointment: 

  1. Complete a Clinical Review Update Note* in the client’s record. This is a non-billable note and you do NOT need to wait until the client's next appointment. 

    *Only complete this note if you receive an email notification about a CCR in which the need for ongoing care is not present AND you are recommending ongoing care for your client.

    To find this in AMD go to Notes→ ”Template”→ ”Clinical Review Update Note”

    Clinical Review Update Note (1).png

    See examples of Clinical Review Update Notes here

  2. Submit the completed Clinical Review Appeal form provided in the email notification you initially received.  A Clinical Care Reviewer will respond to your appeal within 7 calendar days, although this typically occurs much sooner. 
Note: Kaiser will not pay for care that has been determined to be not clinically indicated based on the Clinical Care Review and Rula may not reimburse providers who continue to provide services following a determination that the episode of care is not clinically indicated.

Rula will assign you new clients to fill your caseload as clients complete care if your calendar has slots available for new clients and you have not paused yourself.

Questions about the CCR process?

Contact the Rula Clinical Quality Team at quality@rula.com

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