Covered Services. A Self-study Module. Revised December 2010. Introduction and The Covered Services Guide. Module Contents: Introduction to Covered Services The Covered Services Guide Covered Service Domains Support Services Rehabilitation Services Billing and Documentation
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Covered Services Guide
The behavioral health community is in the midst of national reform. As the system emerges as an effective network, individuals receiving services are recovering and leading productive lives.
culture into account when planning for services.
The ADHS/DBHS ‘Covered Behavioral Health Services Guide’ is the document that lists and defines an array of available services, along with additional information regarding the delivery of these services.
Covered services include treatment, medical, crisis, residential, and transportation services (a complete list of covered service domains is provided later in the module).
These behavioral health services are designed to assist, support and encourage each eligible person (members) to maintain the highest possible level of health and self-sufficiency,
The best way to easily access the most recently updated Guide is to bookmark the ADHS/DBHS internet site for the Guide, or put a shortcut to this site on your desktop!
Click on the ADHD logo to access the Guide
We’ll now begin looking at the various covered services…
For clarity and consistency, ADHS/DBHS has developed and organized the covered services into the following service domains:
This module focuses on the Support and Rehabilitation services. Before we explore those two domains in depth, we’ll look briefly at the other service domains…
Treatment Services are provided by or under the supervision of Behavioral Health Professional (BHPs) to reduce symptoms and improve or maintain functioning. There are three service categories:
services provided by qualified individuals)
Medical Services are provided by or ordered by a licensed physician, nurse practitioner (NP), physician assistant (PA) or nurse to reduce symptoms and improve or maintain functioning. There are four service categories:
Crisis Intervention Services are provided to a member for the purpose of stabilizing or preventing a sudden, unanticipated, or potentially dangerous behavioral health condition, episode or behavior.
Chinese symbol for ‘crisis’
Crisis Services may be provided in various settings, including: at the member’s residence, community sites, emergency rooms, in-office, or over the telephone.
Inpatient Services (including room and board) are provided by an OBHL (see next slide) licensed Level I behavioral health agency. These facilities provide a structured treatment setting with daily 24-hour supervision and an intensive treatment program, including medical support services. There are three service categories:
Residential Services are provided on a 24-hour basis. Costs of room and board is not covered by Title XIX/XXI. There are two service categories, based on the type of facility providing the services:
* OBHL is the Office of Behavioral Health Licensing - a department of ADHS that licenses non-state contracted entities to provide Covered Services.
Behavioral Health Day Programs services are scheduled on a regular basis either on an hourly, half-day or full-day basis and may include services such as therapeutic nursery, in-home stabilization, after school programs, and specialized outpatient substance abuse programs. These programs can be provided to a person, group of persons and/or families in a variety of settings. There are three service categories, based on the level/type of staffing:
Prevention Services promote the health of persons, families and communities through education, engagement, service provision and outreach.
That was a quick look at 7 of the 9 services domains
In the Covered Services Guide.
Next we will look in depth at the 2 remaining domains:
Support Services and Rehabilitation Services…
Support Services are provided to facilitate the delivery of or enhance the benefits received from other behavioral health services. The goal is to help the member to be as self-sufficient and independent as possible.
These Support Services in the Covered Services Guide have been grouped into the following categories:
Case Management services include activities and services performed by behavioral health staff that facilitate the execution and effectiveness of the covered services provided to their members.
Some facts regarding case management services:
(assessment and nursing services are the other two).
present (family support is another).
Case management services do not include:
of service or utilization review.
Covered Services Guide - Case Management
cannot be billed when the CM activity is part of
another Covered Service.
Case Management services include these activities:
Case Management services may also include these activities:
Case Management services can by provided by: Behavioral Health Professionals (BHPs), Behavioral health Technicians (BHTs), and Behavioral Health Paraprofessionals (BHPPs).
If Case Management services are not provided by Behavioral Health Professionals (BHP), these services must be provided under their direction or supervision.
Personal Care services involve the provision of support
activities to assist a member in carrying out daily living tasks
& other activities necessary for living in a community. This is
different from skills training (discussed later) in that the BH
worker directly assists in the member accomplishment
of tasks to help them maintain basic functioning and the
highest possible level of independence.
Examples include directly assisting members with:
- self-administration of medications - grooming and personal hygiene - preparing food - cleaning or maintaining a living space
This assistance may be ‘hands on’ or involve demonstration or ‘cuing’.
Personal Care services can by provided by: BHPs, BHTs, and BHPPs.
Family Support services involve interaction with family
member(s) directed toward restoration, enhancement, or
maintenance of the family functioning to increase the
family’s ability to effectively interact and care for the
member in the home and in the community.
Examples include assisting member’s family members with:
-adjusting to member’s disability/disorder; skills for successful interactions with member - understanding treatment of behavioral health issues, including medication effects - utilizing system/available community and natural resources - planning for long-term client care
The family members of the client do not have to be enrolled members in our system to receive these services.
Family Support services can by provided by: BHPs, BHTs, and BHPPs
Peer Support services are provided by persons or family members who are or have been consumers of the public behavioral health system.
Peer support services include:
-assistance with better utilizing the BH delivery system -overcoming service barriers - helping members understand and cope with their disability - accessing supports - mentoring, role modeling or coaching
These services may be provided to a client, group, or family.
Peer Support services may by provided by: BHPs, BHs, and BHPPs
Respite means short term behavioral health services or general supervision that provides rest or relief to a family member or other individual caring for a member.
The Respite may be > planned/scheduled or unplanned.
> provided in a variety of settings - in or out of the home > provided for a few hours, overnight, a weekend, or longer
Respite care needs to be in the Service Plan if it is to be provided!
Interpretive services are offered and provided to members and/or their families with limited English proficiency (LEP) or other communication barriers (e.g. sight or sound) during counseling or other treatment activities that will allow the person to obtain maximum benefit from the services.
This applies to all non-English languages, not just those languages identified as prevalent.
An interpreting service must be reported along with another Covered Service - you can not report it or bill for it alone!
For additional info: Interpreting Services - Provider Manual Section 10.5
Transportation services involve the transporting of a person from one place to another to facilitate the receipt of, or benefit from, medically necessary covered behavioral health services, allowing the person to achieve his or her service goals.
This may include the transportation of a member and/or the member’s family members.
Transporting a client/family member is billed by reporting a base rate and miles transported:
(MapQuest) that depicts the route traveled and miles driven
Transportation services also include bus passes and taxi vouchers.
trip or during each segment of a non-round trip.
Home Care Training to Home Care Client (HCTC)
This was formerly known as Therapeutic Foster Care. It provides training
services to the caregivers who head these foster homes, helping them prepare to provide behavioral health services, psychosocial rehabilitation, skills training and development, etc. to the youth or adults place in their HCTC foster care homes.
These services are provided to assist individuals or families to obtain and maintain housing in an independent community setting - their own residence or those maintained/contracted by provider agencies. This may include rent and utility subsidies and relocation services.
Now, on to the Rehabilitation Services domain…
Rehabilitation Services include the provision of education, coaching, training, demonstration and other services including securing and maintaining employment to remediate residual or prevent anticipated functional deficits.
These Rehabilitation Services in the Covered Services Guide have been grouped into the following categories:
This service involves teaching independent living, social and communications skills to members and/or their families in order to maximize the member’s ability to live and participate in the community and to function independently.
Examples of Skills Training include training/teaching members about:
- self-care; health; recreation - household management; budgeting; shopping - social decorum; support networks; maintaining relationships/friendships - utilizing community resources - using public transportation
Skills Training services may be provided to the member, their family or a group - the member must be present!
Skills Training can by provided by: BHPs, BHTs, and BHPPs
This service involves the facilitation of member recovery from cognitive impairments (due to injury, stroke, etc.) in order to achieve independence or the highest level of functioning possible.
Goals of Cognitive Rehabilitation may include:- relearning of targeted mental abilities and social interaction skills - learning of new replacement skills - controlling emotional aspects of functioning
Training can be done through:- exercises or stimulation - cognitive neuropsychology - cognitive and behavioral psychology
Cognitive Rehabilitation training is generally provided one-on-one and is highly customized to each client’s strengths, skills and needs
Cognitive Rehabilitation can by provided ONLY by: BHPs (or medical personnel)
with specialized training in this area.
This service includes education and/or training to members, their families or groups in single or multiple sessions using a standardized curriculum (attach copy of curriculum to progress note) regarding health topics/issues related to the member’s service plan or their medications.
There are two distinct services/billing codes within this service:
Health Promotion/Education - to increase member and/or family knowledge of health-related topics, i.e., illness; stress management; safe sex practices; healthy lifestyles; relapse issues; HIV risks
Medication Training and Support - education and support provided to a member and/or their family related to a medication regime. This may include information on medication effects, side effects, etc.
Health Promotion/Education can by provided by: BHPs or BHTs (also LPNs/RNs)
These psychoeducational services and ongoing support to maintain employment services are designed to assist a member to choose, acquire and maintain a job or other meaningful community activity (i.e., volunteer work)
There are two distinct services/billing codes within this service:
Psychoeducational Services(pre-job training/development)
▪ Career/educational counseling ▪ Job interview skills
▪ Job shadowing ▪ Appropriate dress/attire
▪ Training in resume preparation ▪ Time management
Ongoing Support to Maintain Employment(job coaching)
▪ Monitoring and supervision ▪ Assistance in performing job tasks
▪ Work adjustment training ▪ Supportive counseling
Vocational Services can by provided by: BHTs or BHPPs with at least one year of experience providing Rehabilitation services
Billing codes are specific to each type of Covered Service and these codes may vary depending on things such as location of service, who is present for service, or the type of drug administered.
General Billing Guidelines…
services - all other services must be provided face-to-face.
For each Covered Service provided you must determine the correct behavioral health service and the total time spent providing each service.
Do not ‘lump’ services together – each distinct service provided must be billed separately.
Billing for Services…
You can bill the first unit of service - regardless of the length of unit time - when 1 or more minutes are spent providing the service.
However, to bill for subsequent units, you must provide service for at least half the time of that billing unit.
For 15 minute billing units:
▪3 minutes of service - bill 1 unit ▪22 minutes of service - bill 1 unit
▪ 24 minutes of service - bill 2 units ▪ 40 minutes of service - bill 3 units
For 30 minute billing units:
▪ 6 minutes of service - bill 1 unit ▪40 minutes of service - bill 1 unit
▪ 50 minutes of service - bill 2 units ▪ 75 minutes of service - bill 3 units
It is important that you document in writing each service provided - this is your progress note.
Your progress note must substantiate the service provided!
Your written progress note must explain/describe the service provided. It must support both the service billed for as well as the amount of time billed.
It is good practice to include in your note the ‘action’ language provided in the description of the service found in the Covered Services Guide.
For example, if providing Skills Training, your probably ‘taught’, ‘demonstrated’ or ‘developed’ skills with the client - these actions would support the billing of this service and should be documented in your note.
Data Validation is the process of reviewing/auditing clinical files to ensure that service encounters/claims billed are supported by records and documentation. This includes timeliness, correctness & omissions of data.
Below are documents you will find useful when learning about, considering, or utilizing Covered Services:
It is also good practice to utilize your Supervisor when questions
regarding Covered Services, billing or documentation arise!
When considering behavioral health services for a member it is important to be familiar with the wide array of covered behavioral health services available to a member based on his/her benefit plan.
This module has provided an overview of Covered Services and the Covered Services Guide
Please Complete the
Post Test / Final Exam
at this time.