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Department of Medical Assistance Services. COMMUNITY MENTAL HEALTH REHABILATATIVE SERVICES. September 2008. ************. This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals

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Department of Medical Assistance Services

COMMUNITY

MENTAL HEALTH REHABILATATIVE SERVICES

September 2008


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************

This presentation is to facilitate training of the subject matter in portions of the

Virginia Medicaid manuals

Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services Manual.

For a complete copy of manual:

www.dmas.virginia.gov


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Accessing CMHRS ManualFrom DMAS Website www.dmas.virginia.gov

After accessing the DMAS website ---follow and click at the red arrow markers (displayed only the slide) to obtain the CMHRS manual


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Objectives of Today’s Training

  • Review general Medicaid provider requirements & staff credentials

  • Discuss Crisis Intervention

  • Discuss Crisis Stabilization

  • Discuss Intensive Community Treatment

  • Discuss Mental Health Support Services

  • Discuss Mental Health Targeted Case Management

  • Discuss Utilization Review

  • Closing questions


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General Medicaid Participation Requirements:

The Provider agency holds a current, signed participation agreement with DMAS and meets the following:

  • Holds in good standing required licensure

  • Has administrative and financial management capacity to meet state and federal requirements.

  • Has the ability to serve individuals needing comprehensive services

  • Provides like quality services to all clients


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Participation Requirements (cont’d)

For recipients providers must:

Assure freedom to accept or reject medical care and treatment

Assure freedom of choice of provider

Alert recipient to notification of the right to appeal


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Participation Requirements(cont’d):Providers must:

Document and maintain individual case records in accordance with state and federal guidelines

Holds information regarding recipients confidential.

Maintain records for a period of not less than 5 years


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Participation Requirements (cont’d):

  • Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements


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Participation Requirements (cont’d):Providers must:

Not exceed the provider’s usual and customary charges to the general public.

Accept as payment in full the amount reimbursed by Medicaid for recipient.

Should not attempt to collect from the recipient or family member any amount that exceeds the Medicaid allowance.


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Provider Enrollment

First Health/Provider Enrollment Unit (FH/PEU)

For enrollment, agreements, change of address, and enrollment questions:

First Health VMAP Provider Enrollment Unit

P.O. Box 26803

Richmond, Va. 23261-6803

Helpline -- 804-270-5105 – Richmond

(in state)Toll free -- 888-829-5373

Fax -- 804-270-7027


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Specific Staff Qualifications

  • DMAS defines a Licensed Mental Health Professional to be a:

    • Physician

    • Licensed Clinical Psychologist

    • Licensed Professional Counselor (LPC)

    • Licensed Clinical Social Worker (LCSW)

    • Licensed Marriage and Family Therapist

    • Psychiatric Clinical Nurse Specialist

    • Nurse Practitioners


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Staff Qualificationscont.

  • Qualified Mental Health Professional – Clinician in the human service field, trained and experienced in providing psychiatric/mental health services to individuals with a psychiatric diagnosis.


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Human Services Fields

  • Social Work

  • Gerontology

  • Psychology

  • Psychiatric Rehabilitation

  • Special Education

  • Sociology

  • Counseling

  • Vocational Rehabilitation

  • Human Services Counseling

  • Nursing


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Definition of“Clinical Experience”

  • Providing direct services to individuals with:

    • Mental illness

    • Mental retardation

    • Persons receiving gerontology services

    • Persons receiving special education services

  • Includes supervised internships, practicums and field experience.


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Staff Qualifications (cont’d)

Qualified Mental Health Professional (cont’d)

  • Psychologist: master’s degree in psychology with at least one year of clinical experience;

  • Social worker: master’s or bachelor’s degree with a least one year of clinical experience;

  • Registered nurse: RN licensed in Virginia with at least one year of clinical experience;


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Staff Qualifications (cont’d)Qualified Mental Health Professional (cont’d)

Mental Health Worker:

  • bachelor degree in human services field with one year clinical experience; OR

  • bachelor’s degree in unrelated field with associates in human services field & three years clinical experience; OR

  • bachelor’s degree in unrelated field with at least 15 semester credits in human service field & three years clinical experience; OR

  • four years clinical experience working directly with individuals with mental illness


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Staff Qualifications (cont’d)

Qualified Para-Professional

  • AA Degree in related field with one year clinical experience; OR

  • AA Degree in unrelated field with three years clinical experience; OR

  • College credits in human service field equivalent to AA degree or higher with one year clinical experience; OR

  • Licensed Practical Nurse with one year clinical experience


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“PARAPROFESSIONAL SUPERVISION”

  • QMHP demonstrates supervision of “Qualified Paraprofessional” by reviewing notes, progress towards achieving ISP goals & objectives and making recommendations for change.

  • Supervision must occur & be documented in the clinical record monthly.

  • Individual & group supervision conducted by the QMHP are acceptable.


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Non-Qualified Paraprofessionals

Paraprofessionals who do NOT meet the experience requirement described may provide services…..

  • if they are working directly with a Qualified Paraprofessional on site and

  • they are supervised by a QMHP.

    Supervision must include on site observations of services, face -to-face consultation, review of notes, etc. and be documented in the clinical record monthly.


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All OF THE COMMUNITY MENTAL HEALTH SERVICES…..

have four specific components:

  • Service Definition

  • Eligibility requirements

  • Activities which are required

  • Limitations of the Service


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Order of UR Forms in Handout Packet

  • Crisis Intervention,

  • Crisis Stabilization,

  • Intensive Community Treatment,

  • Mental Health Support,

  • MH Case Management, &

  • Psychosocial Rehabilitation- (not a part of CMHRS Fall Training, but we will be available for PSR questions during lunch) Link to WebEx recorded training is as follows:

    https://dmas.webex.com/dmas/k2/e.php?AT=RINF&recordingID=10323587



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Crisis Intervention:

SERVICE DEFINITION

FOR NON-HOSPITALIZED INDIVIDUALS

  • Direct mental health care, available 24 hours a day, 7 days per week, to provide assistance to individuals experiencing an acute mental health dysfunction requiring immediate clinical attention.


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Service Definition(cont’d)

The objectives of crisis intervention services are:

  • To prevent exacerbation of a condition;

  • To prevent injury to the recipient or others; and

  • To provide treatment in the least restrictive setting


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Crisis

Intervention Services

Required Licensing Information

  • Crisis Intervention providers must be licensed as a provider of Outpatient Services by DMHMRSAS;

  • Appropriate staff (LMHP, QMHP or certified prescreener) conducts the evaluation or assessment, develops the ISP and delivers the service


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Eligibility Criteria:

CRISIS INTERVENTION SERVICES :

  • Are provided following a marked reduction in the recipient’s psychiatric, adaptive or behavioral functioning or an extreme increase in personal distress

  • Can be provided for an individual with co-occurring mental health and substance abuse services as long as treatment for the substance abuse is intended to positively impact the mental health condition


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Required Activities:

The Crisis Intervention program includes:

  • Psychiatric assessment & medication evaluation

  • Treatment planning

  • Symptom and behavior management

  • Short term individual counseling

  • Referrals to appropriate community resources


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Required Activities(cont’d):

A Certified CSB Prescreener, LMHP or QMHP must:

  • Complete and document a face-to-face assessment of the crisis situation, including the anticipated duration, that warrants the need of the service;

  • Review/Approval of this documentation must be made by an LMHP/certified prescreener within 72 hours (if completed by a QMHP)

  • Provide immediate needed services to the client in the least restrictive setting


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Required Activities,(cont’d):

SERVICES MAY INCLUDE:

  • Home or office visits

  • Telephone contacts/community referrals (or other client-related activities for the prevention of institutionalization)

  • Interventions that include the individual’s family or significant other

  • Preadmission screenings*

  • *Only CSBs can do pre-admission screenings


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Required Activities (cont’d):

  • As appropriate, the client should be referred for a physical examination and this referral should be documented in the record.

  • The quantity and dosage of any prescribed drugs should be documented in the record.

  • As appropriate, Freedom of Choice of medical/psychiatric providers and Appeal Rights should be given to recipient and documented in the record.


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ISP’s and Short Term Counseling:

  • An ISP is not required for crisis intervention services

  • An ISP is required for scheduled short-term counseling

  • The short-term counseling contacts must occur within 30 days of the first face-to-face crisis contact


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ISP’s and Short Term Counseling (cont’d):

  • An ISP prepared by a Certified Pre-Screener or QMHP by the FOURTH face- to- face contact must be developed or revised to reflect treatment goals and interventions for scheduled short term counseling.

  • Inclusion of the service on the existing ISP is not required for the service to be provided to an active recipient on an emergency basis.


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Service Units & Maximum Service Limitations:

  • Crisis Intervention (H0036) and Crisis Stabilization (H2019) may not be billed if the client is receiving Intensive In- Home Services

  • If other clinic services are billed while the individual is receiving Crisis Intervention services, documentation must clearly support the separation of services with distinct treatment goals


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Manual States No CI billing During IIH:

  • Crisis intervention is a part of intensive in-home services and should not be billed separately when a Medicaid recipient is also receiving intensive in-home services. 

  • CSB Emergency Services staff respond to internal and external requests to provide CI services for clients, and are sometimes unaware of the client’s involvement in IIH. 

    1. Crisis staff should ask the child or adolescent and any accompanying adult (if applicable) if they are receiving any other services from any other provider, specifically intensive in-home services.  The question and answer should be clearly documented in the client record. 


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No CI During IIH(cont’d):

  • If the answer is no, provide the crisis service and proceed to item #2 below.

  • If the answer is yes, provide the needed crisis service and then contact the private provider if possible.  This crisis intervention service should not be billed to Medicaid.

    2. During the next business day, Medicaid may be contacted to determine if any provider is rendering intensive in-home services to the client.  The result of this investigation should be documented.


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No CI During IIH(cont’d):

  • If the answer is yes, CI should not be billed to Medicaid

  • If the answer is no, the crisis services can be billed to Medicaid

    **Please note, this process is not applicable for those situations where a CSB is responding to the request to perform a prescreening for potential ECO or TDO.  For those situations, a CSB will be allowed to bill crisis intervention services regardless of whether the client is receiving intensive in-home services from a private provider.  


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No CI or CS During IIH(cont’d):

  • CI providers may review the clients’ services on the Medicaid web site/Provider Help Line prior to billing.

  • Other service providers with releases may be contacted to investigate clients’ involvement.

  • CI providers should clearly document all attempts to gather this information.

  • Preadmission screenings for these IIH recipients are billable under the CI service code.

  • During a UR, this documentation will likely avoid the need for the repayment of crisis services.


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Service Units & Maximum Service Limitations(cont’d):

  • A face-to-face contact with the consumer must occur during the crisis episode.

  • Other contacts, such as telephone calls and collateral contacts during the crisis episode, are reimbursable as long as the requirement for a face-to-face contact is met and the contacts are directed toward crisis resolution.


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Service Units & Maximum Service Limitations(cont’d):

  • Reimbursement will be provided for short-term crisis counseling contacts scheduled within a 30-day period from the time of the first face-to-face crisis contact.


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Service Units & Maximum Service Limitations(cont’d):

NOTE:

  • Medicaid cannot be billed when a recipient is under Emergency Custody Orders (ECOs) or Temporary Detention Orders (TDOs).

  • Services may be billed up to the time an order is received and after evaluation for ECO/TDO is complete.

  • Documentation must clearly delineate the separation of time.


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Service Units & Maximum Service Limitations (cont’d):

  • A unit of service is 15 minutes of Crisis Intervention

  • A Maximum of 720 units of Crisis Intervention can be provided annually.

  • Staff travel time is not billable


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Crisis Intervention Do’s & Don’ts

  • Do document the time spent in service delivery---including collateral contacts

  • Don’t bill for crisis services after TDO or ECO has been issued




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Outpatient

Service

Provider

Specific Licensure Requirements for this mental health service:

Crisis Stabilization providers must be licensed by DMHMRSAS as a provider of Outpatient Services


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Crisis Stabilization (H2019)

SERVICE DEFINITION

Crisis stabilization services:

  • direct mental health care

  • to non-hospitalized individuals of all ages who are experiencing an acute crisis of a psychiatric nature that may jeopardize their current community living situation.


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Crisis Stabilization (cont’d):

GOALS of the service are to:

  • Avert hospitalization or rehospitalization;

  • Provide normative environments with a high assurance of safety & security for crisis intervention;

  • Stabilize individuals in psychiatric crisis;

  • Mobilize the resources of the community support system, family members & others for on-going maintenance & rehabilitation.


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Eligibility Criteria:

Individuals must demonstrate a clinical necessity for this service arising from a condition due to an acute crisis of a psychiatric nature which puts them at risk of psychiatric hospitalization.


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Eligibility Criteria(cont’d):

The individual must meet at least twoof the following criteria at the time of admission to the service:

1. Experiencing difficulty in maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization, homelessness or isolation from social supports.


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Eligibility Criteria(cont’d):

2. Experiencing difficulty in activities of basic daily living such as….

  • maintaining personal hygiene

  • preparing food & maintaining adequate nutrition or

  • managing finances to such a degree that health or safety is jeopardized.


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Eligibility Criteria(cont’d):

3. Exhibiting such inappropriate behavior that immediate interventions by the mental health or other agencies are necessary.

4. Exhibiting difficulty in cognitive ability such that the individual is unable to recognize personal danger or to recognize significantly inappropriate social behavior.


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Co-morbid Disorders:

  • If the individual has co-occurring mental health and substance abuse disorders crisis stabilization services are allowed as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.


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Required Activities

Psychiatric Assessment & treatment includes….

  • Medication evaluation

  • Treatment planning

  • Symptom & behavioral management

  • Individual & group counseling


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Required Activities (cont’d):

SERVICE may be provided in (but is not limited to):

  • The home of the recipient who lives with family or other primary caregiver;

  • The home of the recipient who lives independently; or

  • Community based programs licensed by DMHMRSAS to provide residential services (but not IMDs).


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Required Activities (cont’d):

A face-to-face assessment must be performed (minimally by a QMHP or Certified Prescreener) that documents:

  • the need for the service

    and

  • the anticipated duration of need.

    Assessment must be reviewed and approved by LMHP within 72 hours.


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Required Activities (cont’d):

  • An ISP is developed by the QMHP within 10 business days of the assessment.

  • Services are provided in accordance with the ISP.

  • Services may be provided by a QMHP, LMHP or a Certified Prescreener.


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CS ISP Key Elements:

  • Include all CS areas of need from the assessment to meet service definition

  • ISP components must be individualized

  • Objectives= desired client behaviors, be specific & quantitative

  • Interventions= planned staff actions & planned frequency of provision

  • Include specific target dates


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Required Activities(cont’d):

  • If case management is being provided, there must be coordination with the case management agency.

  • Documentation is created & maintained through daily notes and a daily log of time spent in the delivery of services


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Sample Residential CS Progress note:

October 1, 2008

10:00 AM- 6:00 PM = 8 hours

Gave AM & PM meds and encouraged med compliance. Asked about & repeated info re: medication benefits and side effects. MD completed medication evaluation @ 11 AM. Meds remain the same. Individual counseling re: anxiety & worrying about upcoming divorce, appt. w/ attorney, & custody dispute over 10 year old son. Group counseling re: SA issues while on MH meds. Spoke with husband re: proposed discharge date & supervision for son.


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Sample CS Progress note(cont’d):

Maternal grandmother will pick up client & stay with her @ discharge. Discussed with client.

Provided 1-1 counseling, (reassurance, problem solving, relaxation techniques, & active listening) five times, due to increased anxiety and distress over separation and custody issues. Client able to calm down w/ assistance & felt better by dinner time after speaking with her attorney on the phone. Client will continue to receive CM & MHS at discharge.

Candice Chavis, MA, QMHP

October 1, 2008


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Limitations

NOT a part of this service:

  • Room and board

  • Custodial care

  • General supervision


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Limitations

Service is neither appropriate nor reimbursed for:

  • Individuals with medical conditions which require hospital care;

  • Individuals with a primary diagnosis of substance abuse;or

  • Individuals with psychiatric conditions which cannot be managed in the community, such as individuals who are of imminent danger to self or others.


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Limitations(cont’d):

  • Staff travel time is excluded

  • DMAS will only reimburse for services provided in facilities or programs with no more than 16 beds. This number is determined by all the beds within a program facility, whether or not the services are billed to Medicaid.


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Limitations(cont’d):

  • One exception is separate residences, owned by the same provider, which are both 16 beds or less and the physical distance between these residences are one mile or more.


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Service Units & Limitations

  • A billing unit is one hour.

  • There is a limit of 8 hours a day for up to 15 consecutive days in each episode, up to 60 days annually.

  • No concurrent billing is allowed during the same time period for clinic optionoutpatient mental health services, or intensive community treatment.

  • Billing for medication management only is permitted


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Crisis Stabilization Do’s & Don'ts

  • Do make sure assessments include the anticipated duration of need

  • Services must be authorized by LMHP within 72 hours

  • A greater number than maximum of 15 consecutive days may not be billed per crisis episode


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Crisis Stabilization Do’s & Don'ts

  • A greater number than the maximum of 8 eight hours per day may not be billed.

  • A greater number than the maximum of 60 days. annually may not be billed

  • Don’t bill for Mental Health Clinic Services during crisis stabilization.

  • Do clearly describe all CS services provided to correlate with time.




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Intensive Community Treatment

Required Licensing Information

  • The agency must be licensed by DMHMRSAS as a provider of intensive community treatment services or as a program of assertive community treatment..


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SERVICE DEFINITION:

Intensive Community Treatment (ICT) is….

an array of mental health services….

for adults

  • with a serious emotional illness

  • who need intensive levels of support & service

  • in their natural environment to permit or enhance functioning in the community.


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SERVICE DEFINITION (cont’d):

  • Intensive Community Treatment (ICT) has been designed to be provided through a designated multi-disciplinary team of mental health professionals

  • It is available either directly or on call 24 hours per day, seven days per week, 365 days per year.


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Eligibility Criteria:

The individuals must meet one or more of the following criteria:

  • Is at high-risk for psychiatric hospitalization or for becoming/remaining homeless or requires intervention by the mental health or criminal justice system due to inappropriate social behavior.

  • Has a history (3 months or more) of a need for intensive mental health treatment or treatment for serious mental illness & chemical addiction and demonstrates a resistance to seek out and utilize appropriate treatment options.


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Required Activities(cont’d):

  • Services are provided by a QMHP or a paraprofessional under the supervision of a QMHP or LMHP

  • Services are provided in accordance with the ISP.

  • Documentation is created & maintained through a daily log:

  • of time spent in the delivery of services and

  • a description of the activities & services provided.


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Required Activities (cont’d):

  • Minimally There must also be at least a weekly note documenting progress or lack of progress toward goals & objectives outlined in the ISP and

  • There must be coordination to ensure there is no duplication in services or billing and to ensure continuity of care.


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Sample ICT Progress Note

October 1, 2008

2-5 pm= 3 hours

Client agitated, angry about roommate throwing dirty clothes on the floor & not washing his dishes. Afraid landlord will complain again about dirty apartment. Staff checked with landlord, no complaints. Discussed positive response re: apt. condition w/ cl. & met with cl. & roommate re: housekeeping problems. Went over chore chart.


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Sample ICT Progress Note(cont’d):

Took client to medication evaluation.

Paranoid thinking is noted to be reduced on new injectable meds. Reminded about appt. w/ probation officer on Friday. Discussed last week’s visit to PRS program & encouraged client to visit again next week.

Candice Chavis, MA, QMHP

October 1, 2008


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Service Units & Maximum Service Limitations

  • The service is initially covered for a maximum of 26 weeks. Continuation can occur if authorized for an additional 26 weeks annually.

  • A unit equals one hour.

  • There is a limit of 130 units annually.


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Service Units & Maximum Service Limitations (cont’d):

This is a bundled service. No billing is allowed during the same time period for any mental health clinic services, crisis stabilization, or case management.

1. Services are provided in a community-based residential setting; and

2. Services meet the criteria for crisis stabilization services; and

3. ICT is not billed for the days that crisis stabilization is billed.


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Service Units & Maximum Service Limitations (cont’d):

  • ICT services may be billed if the individual is brought to the clinic by ICT staff to see the psychiatrist. Documentation to support this intervention must be in the individual’s clinical record.


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Service Units & Maximum Service Limitations (cont’d):

  • In preparation for transition to a lesser level of care, if an ICT recipient goes to the clinic independently (as part of the plan of care for transitioning to less intensive services) psychotherapy and medication management services may be billed as ICT services.

  • As part of ICT, psychotherapy and medication management are generally expected to be provided outside the clinic, hospital, or office setting.


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Service Units & Maximum Service Limitations (cont’d):

  • During transition the ICT plan of care must continue to document the need for the intense level of services provided in ICT.

  • Time billed for psychotherapy, medication management, and other clinic services may not exceed twenty-five percent of the total time billed for ICT during this transition period. The transition period is limited to a maximum of eight (8) weeks.


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ICT Do’s & Don’ts:

  • Remember the ISP is initiated at admission.

  • Re-assessment and re-certification/re-authorization of need must be completed by LMHP every 26 weeks.

  • LMHP certification that the ISP contains documentation of the continued need for this service.

  • The need for ICT staff to bring a recipient to the clinic must be clearly documented.



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Mental Health Support Services (H0046)


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Mental Health

Support

Services

Specific Licensure Requirements for this mental health service:

Mental Health Support Services providers must be licensed by DMHMRSAS as a provider of Supportive In-Home Services, Intensive Community Treatment, or as a program of Assertive Community Treatment


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Mental Health Support Service (H0046) Definition:

  • Training and supports to enable individuals to achieve and maintain community stability & independence in the most appropriate, least restrictive environment.

  • Services may be authorized for six consecutive months.


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Minimum age for MHS?

  • While there is no age restriction listed for this service, the treatment focus is on assisting the client with independent living skills and is therefore appropriate for older adolescents and adults.


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Eligibility Criteria:

Individuals must demonstrate a clinical need for this service arising from a condition due to mental, behavioral, or emotional illness which results in significant functional impairments in major life activities.


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Eligibility Criteria(cont’d):

The individual must meet at least twoof the following on a continuing or intermittent basis:

  • Experiencing difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization, homelessness, or isolation from social support.


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Eligibility Criteria(cont’d):

  • Exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary.

  • Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior.


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Eligibility Criteria(cont’d):

  • Require help in basic living skills, such as….

    • maintaining personal hygiene

    • preparing food & maintaining adequate nutrition or

    • managing finances to such a degree that health or safety is jeopardized.


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Eligibility Criteria(cont’d):

Co-Occurring Mental Health and Substance Abuse Disorders:

  • Integrated treatment for both disorders is allowed as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition.

  • The impact of the substance abuse condition on the mental health condition must be documented in the assessment, the ISP, and the progress notes.


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Required Activities:

Agency’s must provide training in or reinforcement of

  • functional living skills

    AND

  • appropriate behavior related to the individual’s ……...


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Required Activities(cont’d):

  • health & safety

  • activities of daily living

  • use of community resources

  • assistance with medication management,

    AND

  • monitoring health, nutrition & physical condition.


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Required Activities(cont’d):

The QMHP must:

Document the assessment or evaluation (or both) PRIOR to initiation or reauthorization of services……no more than 30 days prior to the initiation/re-authorization of services.

Develop an ISP within 30 days of the initiation of services which includes:

--the specific supports & services to be provided AND

--the goals & objectives to be accomplished.


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MHS ISP Key Elements

  • Include all MHS areas of need from the assessment to meet service definition

  • ISP components must be individualized

  • Objectives= desired client behaviors, be specific & quantitative

  • Interventions= planned staff actions & planned frequency of provision

  • Include specific target dates


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Authorization for Service

  • If the assessment is completed by a QMHP, a LMHP must review and sign the assessment. A LMHP must approve the assessment within 30 days of admission and re-authorization of services.


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Required Activities (cont’d):

  • Agency’s must:

  • Provide services in accordance with the ISP.

  • At a minimum, services must be provided by qualified paraprofessionals (QPP) under the supervision* of a QMHP.

  • Review the ISP every 3 months, modify, update; rewrite the ISP at least annually.


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Supervision of QPPs

  • Supervision by the QMHP or LMHP is demonstrated by a review of progress notes, the individual’s progress toward achieving ISP goals and objectives, and recommendations for change based on the individual’s status.

  • Documentation that supervision occurred must be in the consumer’s clinical record and signed by the QMHP or LMHP. Individual, group, or a combination of individual and group supervision conducted by the QMHP or LMHP with paraprofessionals is acceptable.

  • Supervision must occur monthly.


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Supervision (cont’d):

  • Paraprofessionals, who do not meet the experience requirement listed in Chapter II, may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and supervised by a QMHP.

  • Supervision must include on-site observation of services, face-to-face consultation with the paraprofessional,a review of progress notes, the individual’s progress towards achieving ISP goals and objectives, and recommendations for change based on the individual’s status. Supervision must occur and be documented in the clinical record monthly.


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Required Activities(cont’d):

  • Continuation of services may be authorized by the LMHP at 6-month intervals or following any break in services, based on an assessment and documentation of continuing need.

  • A “break in service” is more than 30 days or if a case has been closed to this service.


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Required Activities(cont’d):

  • Services must be documented through a dailylog of time involved in the delivery of services and a minimum of a weekly summary note of services provided.

  • Per contact daily notes are strongly recommended to ensure all billable services are described.

  • If case management is being provided, there must be coordination with the case management agency.


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Sample MHSS Progress Note

October 1, 2008

1-4 PM= 3 hours

Met client at home to practice bus route to doctor’s office. He looked sad and tired with flat affect, minimal eye contact. He did have his bus schedule and exact change ready. Said he was worried about making the change to the second bus at Main Street. Staff assured him, they would practice until he became more comfortable before he would be asked to go out on his own. On the bus, he became more animated telling staff about his old school they passed & other personal memories.


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Sample MHSS Progress Note(cont’d):

Client was well groomed with clean clothes and wearing his new shoes. Staff complimented him on his appearance. He said he need more toothpaste & staff said they would stop at the drugstore on way home. Discussed budgeting and cash on hand after paying rent last week. No problem getting next bus. He talked clearly & accurately about his progress with psychiatrist and got his prescription. Staff gave praise.

Candice Chavis, MA, QMHP

October 1, 2008


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Limitations:

Interventions that are NOT a part of this service:

  • Academic services

  • Vocational services

  • Room and board

  • Custodial care

  • General supervision


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Limitations(cont’d):

  • Individuals who reside in facilities whose license requires that staff provide all necessary services (including, but not limited to group homes or nursing facilities) are not eligible for this service.

  • Only direct face-to-face contacts & services to the recipient are reimbursable.

  • Staff travel time is excluded.


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Service Units & Maximum Service Limitations:

  • One unit is 1 - 2.99 hours

  • Two units= 3 - 4.99 hours

  • Three units= 5 - 6.99 hours

  • Four units= 7+ hours

  • There is a limit of 372 units per year.

  • Time may be accumulated to reach a billable unit. Service time must be added consecutively to reach a billable unit of service.


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MHSS Do’s & Don’ts:

  • Do have services authorized initially or re-authorized every 90 days by LMHP

  • Do have an assessment completed by QMHP and not more that within 30 days prior to service initiation

  • Don’t miss a re-assessment and re-authorization after a break in service of more than 30 days


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MHSS Do’s & Don’ts

  • Don’t have missing documentation of monthly supervision of QPPs by QMHP.

  • Don’t bill Medicaid for services not provided “face to face”.

  • Do clearly describe all billable services provided in progress notes to correlate with time.




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MH

Case Management

LICENSURE REQUIREMENTS

The provider must be licensed as a provider of

Case Management Services by DMHMRSAS.


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Service Definition for Case Management

Mental health case management services assist individual children and adults in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs.


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Assessment

  • An assessment must be completed by a qualified mental health case manager to determine eligibility and the need for services. (See handout)

  • The assessment serves as the basis for the ISP


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Assessment (cont’d):

  • The referral/assessment information must be documented in the clinical record.

  • Billing cannot occur before face-to-face contact with the client occurred


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Duties of the Case Manager

  • Assisting the individual directly in developing or obtaining needed resources

  • Coordinating services and treatment planning with other agencies


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Duties of the Case Manager

  • Enhancing community integration through community access, involvement and creating opportunities to enhance community living skills


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Duties of Case Manager (cont’d):

  • Making collateral contacts with significant others to promote implementation of the service plan and community adjustment

  • Monitoring service delivery through contacts with service providers as well as periodic site visits and home visits

  • Education & Counseling


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Case Managers and the ISP

The assessment serves as the basis for the ISP


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Case Managers and the ISP (cont’d):

The ISP must document the need for case management and :

  • be completed within 30 days of the initiation of service

  • be cosigned by the recipient


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Case Managers and the ISP (cont’d)

  • be developed by qualified mental health case manager

  • be based on appropriate assessment and supporting documentation


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Case Managers and the ISP (cont’d):

The case manager must modify the ISP as necessary, review it every three months and rewrite it annually

Modifying the ISP as necessary includes whenever the amount, type or frequency of services rendered by the individual service provider changes


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CM ISP Key Elements

  • Include all areas of need from the assessment (legal, financial, health, mental health, housing, etc.)

  • ISP components must be individualized

  • Objectives= desired client behaviors, be specific & quantitative

  • Interventions= planned staff actions & planned frequency of provision

  • Include specific target dates


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Case Managers and the ISP

Review of ISP includes a determination of whether service goals and objectives are being met, satisfaction with the program and whether any modifications to the ISP are necessary

Providers must coordinate reviews of the ISP with the case manager every 3 months


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Quarterly Reviews

  • The first quarterly review will be due the last day of the third month from the date of the ISP

  • Each subsequent review will be due by the last day of the third month following the month in which the last review was due and not on the date when the review was actually completed in the grace period


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Grace period for Quarterly Reviews

A grace period will be granted up to the last day of the fourth month following the month the review was due


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Active Client

Recipient must be an “active client” : have an ISP in effect which requires regular direct or client related contacts and communication


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Active Case Management

  • At a minimum, client-related linking, monitoring, and coordinating at least monthly


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Limitations

  • Case management services are intended to be an individualized client-specific activity between the case manager and the recipient. There are some appropriate instances where the case manager could offer case management to more than one recipient at a time


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CM With More Than One Client

  • Two roommates have appointments with DSS on same day

  • Staff and two clients go to DSS and case manager provides monitoring & coordination for both

  • This counts as active CM services to both recipients

  • Progress notes should describe all CM services provided to each client


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Limitations (cont’d):

  • Case management services for the same individual must be billed by only ONE type of case management provider

  • Billing can be submitted for an active client only for months in which direct or client-related contacts, activity or communications occur.


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Limitations (cont’d):

There shall be no maximum service limits for case management services except for individuals residing in institutions or medical facilities. For these individuals who are not age 21-64 years and in an institution for mental disease (IMD), reimbursement for case management shall be limited to one month of service 30 days immediately preceding discharge.


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Limitations (cont’d):

Case management for institutionalized individuals may be billed for no more than 2 discharge periods in 12 months. Reimbursement for case management services for individuals age 21-64 in IMDs is not allowed.


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CM Do's

  • Do document detailed monthly notes showing activities performed for that month

  • Do have at least one face-to-face meeting with the recipient every 90 days

  • Do provide mandatory monthly case management contact, activity, or communication relevant to the ISP

  • Do utilize your service review summary and chapters IV and VI in the CMHRS provider manual as a guide


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CM Don’ts

  • Write a brief, general summary of active CM services provided for the monthly case management note

  • Bill for case management services while recipient is receiving Intensive In Home services

  • Forget to use specific objectives & interventions on the ISP for monitoring, linking, and coordinating services

  • Put a new date on an old ISP and consider it rewritten


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Case Management: An Overview

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Questions

? ? ?



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Federal regulations require that DMAS review and evaluate the services provided through the Medicaid program……………


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Purpose of Utilization Review the services provided through the Medicaid program……………

Ensure clinical necessity and that an appropriate provider delivers the services

Ensure the provision of quality health care

Ensure program integrity


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General the services provided through the Medicaid program……………UR Facts

  • Reviews are initiated on a regular basis to meet federal requirements or by referrals and complaints from agencies or individuals

  • Reviews are unannounced

  • A random sample from the provider's Medicaid billing is selected for review

  • An expanded review may be conducted if an excessive number of exceptions or problems are identified


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Your UR Site Visit the services provided through the Medicaid program……………

Record Review will include:

  • Request to review program and billing records in a central location

    The Review may include:

  • Observation of service delivery

  • Face-to-face/telephone interviews with the consumer and/or family

  • Review of staff qualifications


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Reviewers check that: the services provided through the Medicaid program……………

  • Services provided meet all requirements defined and described in the DMAS Service manual

  • Services billed match documented delivered care

  • Services do not exceed specific service limitations


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“The UR “Golden Rule” the services provided through the Medicaid program……………

Delivered services as documented are consistentwith the recipient’s Individual Service Plan, submitted invoices and specified servicelimitations .


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Reporting Process the services provided through the Medicaid program……………

After the review, UR staff will conduct an exit conference to describe findings

  • Written report follows within 4 weeks

  • Providers may request a reconsideration


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Reconsideration of the findings: the services provided through the Medicaid program……………

Process has 3 phases-

  • Written response and reconsideration to preliminary findings (30 days to submit information)

  • The informal conference (30 days to request informal conference)

  • The formal evidentiary hearing (30 days to request formal hearing)


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Overpayments required when: the services provided through the Medicaid program……………

  • Medicaid billed contrary to regulation or statute

  • Provider fails to maintain any record or adequate documentation to support the claim

  • Provider bills for an unnecessary service

  • Error found in computing billing amounts


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Questions the services provided through the Medicaid program……………



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Thank address:

You!

www.dmas.virginia.gov


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