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Department of Medical Assistance Services

Department of Medical Assistance Services

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Department of Medical Assistance Services

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  1. Department of Medical Assistance Services CHILDREN’S COMMUNITY MENTAL HEALTH SERVICES: Therapeutic Day Treatment H0035HA Intensive In-Home Services H2012 Intensive In-Home Assessment H0031 Community-Based Residential Services (Level A) H2022 Therapeutic Behavioral Services (Level B) H2020 September 2009

  2. ************ 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

  3. Accessing CMHRS ManualFrom DMAS Website www.dmas.virginia.gov After accessing the DMAS website ---follow and click at the red arrow markers (displayed on the slide) to obtain the CMHRS manual

  4. Methods to verify recipient Medicaid eligibility and services units used MediCall • Available 24 hours a day, 7 days a week • Medicaid Eligibility Verification • Claims Status • Prior Authorization Information • Primary Payer Information • Medallion Participation • Managed Care Organization Assignment

  5. MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

  6. Automated Response SystemARS • Web-based eligibility verification option • Free of Charge. • Information received in “real time”. • Secure • Fully HIPAA compliant

  7. Registration Process https://uac.fhsc.com/uac/pages/unsecured/common/home.jsf • Select the ARS tab on FHSC ARS Home Page • Choose “User Administration” • Follow the on-screen instructions for help with registration, this is a 3-step process to request, register and activate a new account • Answer the initial ‘Who are you?’ question by selecting ‘I do not have a User ID and need to be a Delegated Administrator’

  8. ARS –Users • Web Support Helpline- 800-241-8726

  9. Provider Call Center Claims, covered services, billing inquiries: 800-552-8627 804-786-6273 8:30am – 4:30pm (Monday-Friday) 11:00am – 4:30pm (Wednesday)

  10. Submitting a Prior Authorization (PA) Request via iEXCHANGE® • The preferred method for submitting a PA request is the iEXCHANGE® web-based program • Registration required • Information may be found by going to the KePRO website https://dmas.kepro.org For questions call 1-888-827-2884 or email at ProviderIssues@kepro.org

  11. Objectives of Today’s Training • Review General Medicaid provider requirements & staff credentials • Discuss Therapeutic • Day Treatment • Discuss Intensive In Home Service & Assessments • Discuss Residential Services Level A & B • Discuss Utilization Review • Closing questions

  12. General Provider Medicaid Participation Requirements: The Provider agency holds a current, signed participation agreement with DMAS and meets the following: • Is In good standing with licensure (DBHDS) • 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

  13. Provider 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

  14. Provider 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

  15. Provider Participation Requirements (cont’d): • Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements

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

  17. 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

  18. HEALTH SAFETY & WELFARE ISSUES From 12VAC30-50-335 (M)Providers are required to report suspected abuse , neglect, or exploitation of children or vulnerable adults immediately to DSS………. In addition, participating providers must inform their staff that they are mandated reporters and provide education regarding how to report suspected adult abuse, neglect, or exploitation. • Report Child Abuse/Neglect to Child Protective Services (CPS) In Virginia: (800) 552-7096 • Report Adult Abuse to Adult Protective Services (APS) APS hotline at: (888) 832-3858.

  19. Specific Staff Qualifications • Licensed Mental Health Professional (LMHP) • Physician • Licensed Clinical Psychologist • Licensed Professional Counselor (LPC) • Licensed Clinical Social Worker (LCSW) • Licensed Marriage and Family Therapist • Psychiatric Clinical Nurse Specialist • Psychiatric Nurse Practitioners • School Psychologist • An individual working towards licensure and supervised by the appropriate licensed professional in accordance with the requirements of the individual profession.

  20. 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.

  21. Human Services Fields • Social Work • Gerontology • Psychology • Psychiatric Rehabilitation • Special Education • Sociology • Counseling • Vocational Rehabilitation • Human Services Counseling • Nursing

  22. 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.

  23. 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;

  24. 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

  25. 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

  26. “PARA-PROFESSIONAL SUPERVISION” • QMHP demonstrates supervision of “Qualified Para-professional” 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.

  27. Non-Qualified Para-professionals Para-professionals who do NOT meet the experience requirement described may provide services….. • if they are working directly with a Qualified Para-professional 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.

  28. All OF THE COMMUNITY MENTAL HEALTH SERVICES….. have four specific components: • Service Definition • Eligibility requirements • Activities which are required • Service Limitations

  29. Therapeutic Day Treatment for Children & Adolescents(H0035HA) SERVICE DEFINITION • Psychotherapeutic interventions combined with medication education and mental health treatment • Offered in programs of 2 or more hours per day with groups of children/adolescents

  30. Does the childmeet the eligibilitycriteriafor the service?

  31. TDT Eligibility Criteria: Individual demonstrates a: • Mental, behavioral or emotional illness resulting in significant functional impairments in major life activities • Impairment has become more disabling over time • Require significant intervention services offered over a period of time that are: • Supportive & Intensive

  32. TDT Eligibility Criteria (cont’d): Individuals must meet at least two: 1. Difficulty in establishing or maintaining normal interpersonal relationships (at risk of hospitalization or out-of-home placement because of conflicts with family/community) 2. Exhibit inappropriate behavior: Repeated interventions by the community by mental health agencies by social service agencies by judicial system

  33. TDT Eligibility Criteria (cont’d): 3. Exhibit difficulty in cognitive ability: Unable to recognize personal danger OR significantly inappropriate social behavior • This service is designed for youth who meet one of the following: • Require year-round treatment in order to sustain behavioral or emotional gains, • or

  34. TDT Eligibility Criteria (cont’d): • Have behavior/emotional problems so severe they cannot be handled in self-contained or special classrooms (ED) without this programming during the school day or as a supplement to the school day/year, or • Would otherwise be placed on homebound instruction because of behavior, or

  35. TDT Eligibility Criteria (con’t) or Have deficits in: • social skills • peer relations • dealing with authority • are hyperactive • have poor impulse control • are extremely depressed • marginally connected with reality or

  36. TDT Eligibility Criteria (con’t) or • Preschool child in an enrichment & early intervention program & cannot function in this program (due to the severity of their emotional/behavioral problems) without these additional services.

  37. TDT Required Activities: Before service initiation: • A face-to-face diagnostic assessment is completed minimally by a QMHP with review & approval by LMHP prior to service initiation. • The assessment must be reviewed and updated at least annually.

  38. Assessment Code for TDT: • The Assessment billing code is H0032 Modifier U7 • Assessment codes never require PA • Limit is 2 per provider per fiscal year • Used for new and existing recipients (initial and reassessment) Available as of 8/1/2009 • Provider bills assessment code with modifier for 1 unit. • Reimbursement allowed is a flat rate of $38.05/unit

  39. New Admissions: • Individuals that have not had treatment January 1, 2009 and dates forward are considered new admission cases. • Must bill the appropriate assessment code (with modifier) to determine needs • The provider gets 5 units without PA only first time in treatment.

  40. New Admissions: • If services are to continue (beyond the allowable units without PA), provider must contact KePRO to obtain PA. PA will be allowed for up to 6 month increments • Provider bills assessment, then bills 5 units without PA • Bills the remaining units with PA #

  41. New Admissions: • Must submit a PA request to KePRO after the assessment and before the 5 units without PA are used • If no PA after the 5 units--- claims will deny

  42. Existing Recipients: • Individuals currently receiving services are defined as those that have claims activity in MMIS with DOS on or after January 1, 2009. • System edit will look to see if previous service claims are found, classify as existing recipient and PA will be required for services - there is no 5 unit service limit for “existing individuals” • May bill for “reassessment” to determine continued need for services (2 per provider per fiscal year for each service and does not require PA)

  43. Existing Recipients: • If the assessment is billed prior to 12/31/09, a PA is needed immediately • If you do not bill the assessment prior to 12/31/09, claims will continue to pay through 12/31/09 • PA is mandatory 1/1/10 for existing recipients or claims will not pay.

  44. TDT Required Activities: • An ISP must be completed by a QMHP, documenting the need for services within 30 days of service initiation. • The ISP must be cosigned by the recipient.

  45. TDT ISP Requirements: • Comprehensive and regularly updated • Specific to individual being treated • Containing goals and measurable objectives to meet identified needs • Services to be provided with recommended frequency to accomplish the measurable goals and objectives • Estimated timetable for achieving the goals and objectives • Maintained up to date as the needs and progress of the individual changes,

  46. TDT ISP DO’s: • INDIVIDUALIZED! • Include all service needs identified in assessment • Objectives = specific desired client behaviors in quantitative terms • Interventions = specific planned staff actions with a specific planned frequency • Services must be provided according to the ISP (minimally by QPPs under the supervision of a QMHP)