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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

Covered Services

A Self-study

Module

Revised

December 2010


Introduction and the covered services guide

Introduction andThe Covered ServicesGuide


Introduction

  • Module Contents:

    • Introduction to Covered Services

    • The Covered Services Guide

    • Covered Service Domains

    • Support Services

    • Rehabilitation Services

    • Billing and Documentation

    • Module Review/Summary

Introduction


Introduction1

  • Module Objectives:

  • After completing this module, learners should understand:

    • The purpose of Covered Services

    • The information contained in the

      Covered Services Guide

    • What Service Domains and Services are covered

    • The services available in the Support Services domain

    • The services available in the Rehabilitation Services domain

    • Proper billing and documentation procedures

    • Where to find additional information and assistance

Introduction


Introduction2

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.

Introduction

  • Several key trends have played into this reform, including:

  • Recovery-based services: research indicates that using the right

  • mix of services to meet the needs of the member and family is

  • critical for recovery.

  • Family-centered practices: to promote recovery,

  • it is important to actively include members, families

  • and their supports in services.

  • Cultural focus: it is vital to take the member’s own

    culture into account when planning for services.


Introduction3

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.

Introduction

COVERED

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 covered services guide

Facts about the Covered Behavioral Health

Services Guide:

The Covered Services Guide

  • The Guide is maintained online by the Arizona Department of Health Services - Division of Behavioral Health Services (ADHS/DBHS).

  • The Guide is updated quarterly by ADHS/DBHS

  • Additional new Guide information may be found in a monthly ADHS/DBHS newsletter called ‘Tidbits’.

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


The array of covered behavioral health services

The Array of Covered Behavioral Health Services


Covered services general

Regardless of the service provided, the following guidelines exist:

Covered Services - General

  • Services are not limited based on the gender or age of the individual, but may be limited based on his/her specific benefit plan as outlined in the CPSA Member Handbook.

  • Many services are available to non-enrolled family members.

  • Services may be provided in-office, in-home, or in the community.

  • Each service must be provided by qualified staff (certain qualifications are required) as identified by the Guide.

We’ll now begin looking at the various covered services…


Covered services service domains

For clarity and consistency, ADHS/DBHS has developed and organized the covered services into the following service domains:

  • Crisis Intervention Services

  • Inpatient Services

  • Residential Services

  • Behavioral Health Day Programs

  • Prevention Services

Covered Services - Service Domains

  • Treatment Services

  • Rehabilitation Services

  • Medical Services

  • Support Services

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…


Service treatment services 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:

Service Treatment Services Domains

  • Behavioral Health Counseling and Therapy (in or out of office)

  • Individual Counseling and Therapy - includes Hypnotherapy

  • Family Counseling and Therapy - with or without client; multi-family group OK

  • Group Counseling and Therapy

  • Assessment, Evaluation and Screening Services

  • Gathering and assessment of historical and current information which includes face-to-face with the member and/or their family, resulting in a written summary report and recommendations. (Assessment services may also occur over the phone.)

  • Services include: intake assessment, psychological testing, alcohol and drug assessment.

  • Other Professional(additional treatment

    services provided by qualified individuals)

  • Services include: biofeedback; alcohol/drug outpatient services; traditional healing services; acupuncture.


Service medical services domains

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:

Service Medical Services Domains

  • Medication Services

  • Drugs prescribed and/or administered by a physician, NP or PA, to prevent, stabilize or ameliorate symptoms arising from a behavioral health condition or its treatment.

  • Medical Management

  • Medication Management - review effects and side effects; adjust type and dosage

  • Medical Evaluation/Management - diagnosis, coordination of care, symptom management

  • Laboratory, Radiology and Medical Imaging

  • Tests ordered for diagnosis, screening or monitoring of a behavioral health condition.

  • Examples include: Blood/urine tests; CT scans; MRI; EKG; EEG

  • Electro-Convulsive Therapy (ECT)


Service crisis intervention services domains

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.

Service Crisis Intervention Services Domains

Chinese symbol for ‘crisis’

  • These intensive and time-limited services may include:

    • screening, assessment, and evaluation

    • counseling to stabilize the crisis situation

    • medication stabilization and monitoring

    • observation and/or follow-up to ensure stabilization

    • other therapeutic and support services to prevent, reduce or eliminate a 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.


Service inpatient services domains

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:

Service Inpatient Services Domains

  • Hospital:Provides continuous treatment that includes general psychiatric care, medical detoxification, and/or forensic services in a general hospital or a general hospital with a freestanding psychiatric facility. Includes 24-hour nursing supervision and physicians on site and on call.

  • Subacute Facility: Continuous treatment to a person experiencing acute and severe behavioral health symptoms and/or substance abuse symptoms. Includes 24-hour nursing supervision and physicians on site or on call.

    • May include crisis intervention services provided in a subacute facility without admittance.

    • Service examples: emergency assessment; crisis intervention and stabilization; counseling, detoxification and referral.

  • Residential Treatment Center (RTC): Inpatient psychiatric treatment, which includes an integrated residential program of therapies, activities, and experiences provided to members who are under 21 years of age and have severe or acute behavioral health symptoms. Two types of RTCs: Secure - security guards, locked doors, monitoring equipment and Non-secure - unlocked RTC.


Service residential services domains

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:

Service Residential Services Domains

  • Behavioral Health Short-Term (Level II) Residential: Residential services that are provided by an OBHL* licensed Level II behavioral health agency. These agencies provide a structured treatment setting with 24-hour supervision and counseling or other therapeutic activities for persons who do not require on-site medical services; under the supervision of an on-site or on-call Behavioral Health Professional (BHP).

  • Behavioral Health Long-Term (Level III) Residential (Non-medical, Non-acute): Residential services that are provided by an OBHL* licensed Level III behavioral health agency. These agencies provide 24-hour supervision and intermittent treatment in a group residential setting to members who are determined to be capable of independent functioning but still need some protective oversight to insure they receive needed services.

* OBHL is the Office of Behavioral Health Licensing - a department of ADHS that licenses non-state contracted entities to provide Covered Services.


Service behavioral health day programs domains

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:

Service Behavioral Health Day Programs Domains

  • Supervised Behavioral Health Treatment and Day programs: activities related to enrolled member’s treatment/service plan designed to improve their ability to function in the community. May include: skills training and development; behavioral health prevention/promotion; medication training and support; ongoing employment support; self-help/peer services. Services provided by BHTs, BHPPs, or BHPs.

  • Therapeutic Behavioral Health Services and Day Programs: services provided as listed above, plus: counseling and therapy; home care training (family support); case management; medical monitoring. Services must be provided by or under the supervision of a BHP.

  • CommunityPsychiatric Supportive Treatment and Medical Day Programs: services provided as listed above, plus: other nursing services such as medication monitoring, methadone administration, and medical/nursing assessments. Services must be under supervision of licensed medical staff (MD, NP, or PA).


Service prevention services domains

Prevention Services promote the health of persons, families and communities through education, engagement, service provision and outreach.

Service Prevention Services Domains

  • These services may involve:

  • Implementation of interventions to reduce risk, increase resilience, and promote

  • overall behavioral health in targeted communities and individuals and families.

  • Education to the general public on improving mental health and to general health providers and other professionals on recognizing and preventing behavioral health disorders and conditions.

  • Identification and referral of persons and families who could benefit from behavioral health treatment services.

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…


Covered services

ServiceSupport ServicesDomains

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

  • Personal Care

  • Family Support

  • Peer Support

  • Unskilled Respite Care

  • Interpretive Services

  • Transportation

  • Supported Housing

  • Home Care Training to Home Care Client


Covered services

Support Services: Case Management

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:

  • This is one of only three covered services that may occur over the phone

    (assessment and nursing services are the other two).

  • It is one of the few covered service that can occur without the member being

    present (family support is another).

Case management services do not include:

  • Administrative functions such as authorizations

    of service or utilization review.

  • The performing of services in other areas of the

    Covered Services Guide - Case Management

    cannot be billed when the CM activity is part of

    another Covered Service.


Covered services

Support Services: Case Management

Case Management services include these activities:

  • Coordination of care activities related to continuity of care.

  • Assistance in finding/securing resources other than covered services.

  • Outreach and follow-up to crisis contacts and missed appointments

  • Staffings or CFT/ART meetings with or without the member present

  • Picking up and delivering member medications.

  • Brief telephone or face-to-face interactions with a person, family member or other involved party.


Covered services

Support Services: Case Management

Case Management services may also include these activities:

  • Written electronic communication (email):

    • Must be about a specific member

    • Put copy of email in member’s record

    • Case Management does not include reading emails or texting

  • Leaving a voice message:

    • Sufficient documentation of service provided/addressed

    • Signed document in member’s chart granting permission to use this method of communication

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.


Covered services

Support Services: Personal Care Services

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.


Covered services

Support Services: Home Care Training Family (Family Support)

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


Covered services

Support Services: Self Help/Peer Support Services (Peer Support)

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


Covered services

Support Services: Unskilled Respite Care

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 is available to all populations.

  • Respite providers must be oriented to the needs of the member prior to the respite service being provided and meet certain qualifications.

  • Respite is limited to 30 days or 720 hours per fiscal year (July 1 to June 30).

  • Enrolled parents may receive Respite Care for their non-enrolled children.

  • Non-enrolled siblings of an enrolled child are not eligible for Respite Care

Respite care needs to be in the Service Plan if it is to be provided!


Covered services

Support Services: Sign Language or Oral Interpretive Services

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.

  • Interpretive Services can only be provided by:

    • Certified Bilingual Staff

    • Contract Interpreters

    • Telephone Interpreter service - CyraCom International

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


Covered services

Support Services: Transportation

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:

  • a base rate is each trip provided to the person

  • mileage is calculated from when the person enters the vehicle to when they exit the vehicle

  • When documenting/billing for transportation, the progress note must include:

  • the member’s diagnosis and other information showing the relevance of the trip

  • beginning and ending odometer readings oracopy of mapping software map

    (MapQuest) that depicts the route traveled and miles driven

Continued…


Covered services

Support Services: Transportation

  • Members or family members may also be transported by a contract transportation service. When documenting/billing for contract transportation, the progress note must include:

  • a summary report of the transportation event

  • it is advisable to include any documentation provided by the contracting

    company

Transportation services also include bus passes and taxi vouchers.

Provider Travel

  • There are instances when staff may bill for traveling alone while providing Covered Services…

  • Miles are reported/billed for only if you travel more than 25 miles per round

    trip or during each segment of a non-round trip.

  • The first 25 miles are not billed, only those miles driven beyond the first 25.

  • Beginning and ending odometer readings must be documented in the note.

  • Provider travel does not affect mileage reimbursement you receive from

    your agency.


Covered services

Support Services: Additional Services

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.

Supported Housing

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…


Covered services

ServiceRehabilitation ServicesDomains

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:

  • Living Skills Training

  • Cognitive Rehabilitation

  • Health Promotion/Medication Training

  • Psychoeducational Services for Employment (Vocational Services)


Covered services

Rehabilitation Services: Living Skills Training

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


Covered services

Rehabilitation Services: Cognitive Rehabilitation

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.


Covered services

Rehabilitation Services: Health Promotion/Education

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)


Covered services

Rehabilitation Services: Vocational Services

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


Covered behavioral health services additional information

Covered Behavioral Health Services: Additional Information


Covered services billing

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.

Covered Services - Billing

General Billing Guidelines…

  • Assessment, nursing services and case management are the only services you can bill for over the phone services or face-to-face

    services - all other services must be provided face-to-face.

  • You cannot bill for any ‘no shows’ or cancelled appointments.

  • If you are a supervisor, you cannot bill for supervision time/activities.

  • More than one provider may bill for certain services provided to a member at the same time if indicated by the member’s clinical needs (i.e., for a case staffing or ART/CFT meeting).

  • You cannot bill for any time associated with note taking or updating / maintaining the clinical record.


Covered services billing1

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.

Covered Services - Billing

Billing for Services…

  • Billing units are calculated based on your actual time spent providing the service. You must indicate the begin and end time for each service on the progress note.

  • Most services are billed in15 minute units.

  • Health Promotion is billed in 30 minute units.

  • Some services are billed in 24-hour (per diem) units - i.e., HCTC and Respite.

    \

  • Transportation Services are billed according to mileage, not time.


Covered services billing2

Calculating Billing Units…

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.

Some examples…

Covered Services - Billing

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


Covered services documentation

It is important that you document in writing each service provided - this is your progress note.

Your progress note must substantiate the service provided!

Covered Services - Documentation

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.


Resources

Below are documents you will find useful when learning about, considering, or utilizing Covered Services:

Resources

  • ADHS/DBHS Covered Behavioral Health Services Guide

  • Available on the ADHS/DBHS website

  • CPSA Provider Manual

  • Community Service Agency Resource Guide

  • CPSA Member Handbook

  • The last three documents are available on the CPSA Website:

  • www.cpsa-rbha.org

It is also good practice to utilize your Supervisor when questions

regarding Covered Services, billing or documentation arise!


Module review

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

Module Review

Please Complete the

Post Test / Final Exam

at this time.


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