Substance Abuse Family Evaluation. Preferred Practice Standards

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1 Substance Abuse Family Evaluation Preferred Practice Standards

2 Key Contact Information... 5 Welcome to Project SAFE... 6 History... 6 Program Overview... 6 Project S.A.F.E Covered Services... 7 Evaluation 8 Adolescent Evaluation:... 9 Comprehensive Evaluation:... 9 Individual Therapy 10 Group Therapy 10 Family Therapy 10 Intensive Outpatient Therapy (IOP) 10 Partial Hospitalization Program (PHP) 10 Urine Drug Screens 11 Hair Testing 11 Treatment Levels of Care 11 Service Limitations and Exclusions 12 Level of Care Guide (Table I)...13 Level I: (SA I.1 & SA I.1) Outpatient 13 Level of Care Guide (Table II)...14 Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP) 14 Level of Care Guide (Table III)...15 Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening 15 Referral and Authorization Process...16 Service Authorization and Referral Process for Covered Services...17 Referral and Authorization Process (CHART)...23 Type of Service/Level of Care 23 Information Needed From DCF 23 Information Need from the Provider 23 Information needed or provided by ABH 23 Authorization Requirements 23 Rev. 11/07 2

3 Reimbursement Protocol...24 Provider Credentialing...25 Reimbursement...25 Reimbursement for Evaluation...26 DCF Responsibilities 26 Provider Responsibilities 26 ABH Project S.A.F.E. Will 26 Reimbursement for Treatment...27 DCF Responsibilities 27 Provider Responsibilities 27 ABH Project S.A.F.E. Will 28 Reimbursement for IOP or PHP Levels of Care...29 DCF Responsibilities 29 Provider Responsibilities 29 ABH Project S.A.F.E. Will 29 Reimbursement for Hair Testing...30 DCF Responsibilities 30 Provider Responsibilities 30 ABH Project S.A.F.E. Will 30 Reimbursement for Random Urine Drug Screens Only...31 DCF Responsibilities 31 Provider Responsibilities 31 ABH Project S.A.F.E. Will 31 Requests for Court Cost Reimbursement...33 DCF Responsibilities 33 Provider Responsibilities 33 ABH Project S.A.F.E. Will 33 Special Exceptions...34 Six Tab Web Base Claim System...36 Rev. 11/07 3

4 Complaints, Grievances, and Appeals...38 Appendix A...42 CLIENT REFERRAL FORM (page 1) 42 CLIENT REFERRAL FORM (page 2) 43 Appendix B...44 CLIENT REPORT FORM 44 PROJECT SAFE...44 Appendix C...45 Needs Assessment Form 45 Appendix D...46 TANF ELIGIBILITY SCREENING FORM 46 Appendix E: Outpatient Treatment Request Downloading Procedure...47 Outpatient Treatment Request Downloading Procedure (page 2) 48 Outpatient Treatment Request Downloading Procedure (page 3) 49 Appendix G...51 Special Exception 51 FAQ for Project SAFE Special Exceptions...52 (Formerly Regional Administrator s Approval) 52 Appendix H:...54 Screen Shot of Web-Based Claims System 54 Rev. 11/07 4

5 Advanced Behavioral Health 213 Court Street Middletown, CT Key Contact Information Referral Hotline: Main Number: Billing Department Fax: Advanced Behavioral Health Website: https://www.abhct.com/ Online access to information and materials, such as newsletters, alert memos, and forms. Department of Children and Families Website: Online access to a wide variety of information related to the Department of Children and Families such as newsletters, other publications, and forms. Department of Mental Health and Addiction Services Website: Online access to a wide variety of information related to the Department of Mental Health and Addiction Services such as newsletters, publications, and forms. Rev. 11/07 5

6 Welcome to Project SAFE Welcome to the Advanced Behavioral Health (ABH) Project S.A.F.E. Provider network. As a member of the Project S.A.F.E. Provider network you have joined a group of highly respected behavioral health professionals. We recognize that you share our commitment to improve the quality of life for clients by providing a continuum of high quality accessible behavioral health care services. This Preferred Practice Standards handbook has been developed to inform you of standard practice of participants in the ABH Project S.A.F.E. network The handbook begins with an introduction, states policies and procedures for referral, authorization, claims submission, and the complaints, grievances, and appeal process. Finally, the necessary forms are included, along with a glossary and index for your convenience. Services provided for ABH Project S.A.F.E. clients must be consistent with the practices encompassed in this handbook Should you have any questions, please contact ABH Project S.A.F.E. at: History The Department of Children and Families (DCF) initiated Project S.A.F.E. (Substance Abuse Family Evaluation) in 1995 as a way to connect its child protection system with the adult substance abuse treatment system. DCF contracted with ABH to coordinate central intake and priority access to drug screening, evaluation, and ambulatory treatment for substance abusing primary caregivers of children receiving protective services. DCF began collaborating with the Department of Mental Health and Addiction Services (DMHAS) in October 1999 to identify and address more effectively substance abuse issues and to coordinate and blend state, federal, and private resources to meet the needs of these populations. Program Overview Project S.A.F.E. is a program, jointly funded by DCF and DMHAS, designed to provide priority access to substance abuse evaluation and outpatient treatment services. Clients are eligible for Project S.A.F.E. services if they meet the following criteria: Parents or Primary Caregiver involved in child Protective Services The completed DCF Substance Abuse Screen has identified that substance use/abuse may be effecting the ability to parent effectively and substance abuse treatment or further evaluation is needed; A Referral has been made by DCF Social Worker prior to any treatment and \or evaluation service Funding for Project S.A.F.E. services is provided by DCF and DMHAS, and administered by ABH. This funding system is designed as a payer of last resort. The term payer of last resort indicates that the Project S.A.F.E. funds are used to reimburse providers on a fee-for-service basis when there is no other source of reimbursement available. Rev. 11/07 6

7 Project S.A.F.E. Covered Services There are a variety of services that are reimbursed under Project S.A.F.E. s payer of last resort system. In the following section, we will outline identify and define all services covered by Project SAFE. Rev. 11/07 7

8 Project S.A.F.E Covered Services There are eight basic treatment services that are reimbursable within Project S.A.F.E. Evaluation Individual Therapy (SA I.1) Group Therapy (SA I.1) Family Therapy (SA I.1) Intensive Outpatient Therapy (IOP) (SA II.1) Partial Hospitalization Program (PHP) (SA II.5) Urine Drug Screens Hair Testing The following section contains a description of these services. Evaluation Clients are referred for a Project S.A.F.E evaluation because the DCF Social Worker has completed the DCF substance abuse screen (DCF form 2110) and found reason to believe that the individual s ability to parent effectively is impaired as a result of his/her use. The evaluation is conducted by an approved Project S.A.F.E Provider and consists of a bio-psycho-social assessment focusing on the following areas: Demographic Information Family composition and history Substance abuse history Trauma history Medical history and current medical status DSM IV TR Diagnostic formulation Drug screen results Summary and recommendations Each evaluation should contain a written narrative in the aforementioned areas. Once the evaluation is completed by the provider, the results of the evaluation should be verbally communicated to the DCF Social Worker within twenty-four (24) hours (one business day) of its completion. A written clinical summary will be forwarded to both the Social Worker and the DCF Substance Abuse Specialist within five (5) business days of the evaluation. Rev. 11/07 8

9 In specific cases there are two different evaluation subtypes that may be completed. They are an adolescent evaluation or a comprehensive evaluation. Adolescent Evaluation: Project S.A.F.E. also has capacity to conduct adolescent specific evaluations. The Project S.A.F.E. Adolescent Evaluation Project was initiated in (the then )Region IV to provide Substance Abuse Evaluations to adolescents who are suspected of substance abuse, but do not meet the basic Project S.A.F.E. criteria. DCF Region IV Social Workers who believe that an adolescent would benefit from a Project S.A.F.E. evaluation should complete the following forms prior to contacting the North Central Region ARG: Adolescent Screening Form Project SAFE Referral Form These two forms are then reviewed by the ARG, and approved if clinically appropriate. Once approved, the ARG or designee will call the ABH Intake Coordinator at , and make the referral. Comprehensive Evaluation: The Comprehensive Evaluation Pilot Project began in March 2002, with the following objectives: To develop and standardize a comprehensive bio-psycho-social evaluation for Project S.A.F.E. clients; To collect comprehensive information about the clients served by Project S.A.F.E.; To provide a process for efficient and effective distribution of substance abuse evaluation results. There are ten (10) providers that are participating in the Comprehensive Evaluation Pilot Project. The referral process for this pilot project is as follows: 1. Make an evaluation referral by calling the Project S.A.F.E line 2. Once referred, the provider utilizing a specifically designed Bio-Psycho-social Evaluation that has been standardized will evaluate the client. 3. The form itself is used to collect data and should be completed entirely by the evaluating clinician. 4. Once it is completely filled out, the form is faxed to ABH within thirty (30) days of the date of service for processing. 5. ABH enters all of the information into a database, and then distributes a data processed form to the following: Referring DCF Social Worker; Treatment Provider; Regional Substance Abuse Specialist (if requested). Rev. 11/07 9

10 Individual Therapy Individual therapy consists of one to one therapy in duration of up to one hour, with a frequency of no more than once weekly and no less than once per month. Treatment focuses on reducing symptoms, improving function, maintaining abstinence and relapse prevention. Group Therapy Group therapy consists of therapy in duration up to one and a half hours, with a frequency of once weekly. Treatment focuses on reducing symptoms, providing psycho-education, improving functioning, relapse prevention and maintenance of abstinence. Groups should be limited to no more than twelve (12) clients per group session. Family Therapy Family therapy consists of therapy sessions with a client and one or more individual(s) identified by the client as family, with duration of up to one hour, a frequency of no more than once weekly. Treatment focuses on building and maintaining supports for recovery, repairing relationships, reducing symptoms, providing psycho-education and maintenance of abstinence. Intensive Outpatient Therapy (IOP) A non-residential service provided in a general hospital, private freestanding psychiatric hospital, state operated facility or in a facility licensed by the Department of Public Health as a Psychiatric Outpatient Clinic for Adults. IOP services provides each client with three to four (3-4) hours per day, three to five (3-5) days per week of clinically intensive programming based on an individualized treatment plan. Treatment focuses on reducing symptoms, improving functioning, maintaining community connection and relapse prevention. As a client is preparing for discharge, titration of IOP may occur, decreasing the frequency to less than three (3) times per week. IOP must include one therapy session per day, inclusive of (at least) one individual therapy session per week. Random drug screens can be completed on the same day that a patient attends and are reimbursed separately. Partial Hospitalization Program (PHP) A non-residential service provided in a general hospital, private freestanding psychiatric hospital, state operated facility or by a provider that is a non-profit entity that involves ambulatory intensive psychiatric and/or substance abuse treatment services. PHP services are designed to serve individuals with significant impairment resulting from substance abuse as well as cooccurring psychiatric disorders. These services target adults who have recently been discharged from inpatient facilities, or whose admission to inpatient care may be prevented by treatment in PHP program. PHP consists of therapeutic programming of a minimum of four (4) hours per day, at least four (4) days per week, based on a comprehensive and coordinated individualized treatment plan involving the use of multiple concurrent treatment services and modalities. Treatment focuses on reducing symptoms, improving functioning, maintaining community connection, and relapse prevention. As a client is preparing for discharge, titration of PHP may occur, decreasing the frequency to less than four (4) times per week. PHP must include one therapy session per day, inclusive of (at least) one individual therapy session per week. Random drug screens can be completed on the same day that a patient attends and are reimbursed separately. Rev. 11/07 10

11 Urine Drug Screens Urine drug screens are used to determine the recent use/abuse of substances. Random urine drug screens are defined as two (2) urine drug screens per week for a period of six (6) weeks. Random screens should not occur on the same day and time each week. In order for the screens to be random, the client may be contacted by the treatment provider and asked to come in within the next twenty- four (24) hours for a drug screen, provided it is not on a day when treatment services are provided. Random drug screens can also be requested for a client who is not in active treatment under the following circumstances: In response to a court ordered request or; Has had an evaluation within the past six (6) months. Hair Testing Hair testing is utilized to determine a three-month history of substance use/abuse history prior to the hair test. Careful collection of samples by authorized treatment providers following collection guidelines is necessary to ensure effective use of hair testing. Positive hair test results can be further analyzed to determine if the client s use/abuse of substances occurred within 30/60/90 days prior to collection. This multi-sectional testing can be performed on a positive sample per request of the referring DCF Social Worker. A hair test may be requested for some of the following reasons: Family reunification planning is expected to occur in the immediate future. DCF or provider staff has reason to believe that client has attempted to alter the urine drug screens or failed to keep scheduled appointments. Central or Area Office has concerns about a particular high risk or high profile case. DCF staff identifies cases in which domestic violence is connected with substance abuse. The Court requires documentation of historical drug use during a 30/60/90 day period DCF staff identifies abuse/neglect cases in which the primary caregivers are said to be in recovery from substance abuse. Treatment Levels of Care In this section guidelines adapted from the ASAM Patient Placement Criteria for the Treatment of Substance Related Disorders, Second Edition Revised (ASAM PPC-2R), published by the American Society of Addiction Medicine ASAM in 2001 are used to define treatment levels of care. Each level of care has general characteristics and criteria. Project S.A.F.E provides reimbursement to providers for all of the outpatient levels of care: Outpatient Services Level I SA1.1 Individual Counseling, Family Counseling, Group Counseling, Urine Screens, and Hair test Intensive Outpatient Services Level II, SA II.1 Partial Hospitalization Program Services Level II, SA II.5 In an effort to provide general guidelines, we have included a level of care (page 13-15) table in this Preferred Practices document. It is intended as a guide for clinical practice rather than a set of rules. Rev. 11/07 11

12 Service Limitations and Exclusions A. The following limitations shall apply to substance abuse services performed under Project S.A.F.E a. Covered services and procedures are limited to those listed in the Project S.A.F.E. fee schedule b. At the time of initial referral from the DCF Social Worker the following types of visits can be authorized: i. One (1) evaluation ii. One (1) urine drug screen iii. Twelve (12) random drug screens iv. One (1) hair test v. Undisclosed number of outpatient SA I.1 levels of care c. Medication Management is not a reimbursable service under Project S.A.F.E. B. Reimbursement for the following behavioral health services is excluded under Project S.A.F.E a. Psychiatric evaluation b. Medication Management c. Psychological Assessment d. Services that Project S.A.F.E., DCF and DMHAS determine are not directly related to the diagnosis and treatment of a behavioral health disorder or those that do not reduce symptoms and/or psychological distress. e. Services, consultation or information provided over the telephone f. Services that Project S.A.F.E., DCF and DMHAS determine are primarily for vocational or educational guidance or that is related solely to a specific employment opportunity, work skill work setting and/or the development of an academic skill. g. Breathalyzer h. Methadone Maintenance C. Project S.A.F.E. shall not reimburse for inpatient or residential levels of care. D. Project S.A.F.E. does not reimburse for psychiatric evaluation or medication management. E. Project S.A.F.E. does not reimburse for any required spend-down funding, and/or copayment requirements Rev. 11/07 12

13 Level of Care Guide (Table I) Level I: (SA I.1 & MH I.1) Outpatient Level of Care Level of Care Guide ASAM Description of general criteria Dimension Level I: (SA I.1 & MH I.1) Outpatient Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 Patient has no signs and symptoms of withdrawal. If any biomedical conditions are present, they are sufficiently stable to permit participation in outpatient treatment. Any symptoms of a co-occurring disorder are generally stable, may require some monitoring, and do not interfere with the patient s ability to focus on addiction treatment issues. Mental status does not preclude ability to understand information, and participate in treatment. Patient is willing to participate and cooperate with treatment, acknowledges that he or she has a substance related problem and wants to change. If having difficulty with the above, the patient may need monitoring. Patient is able to achieve abstinence and/or an awareness of a substance related problem The patient s psychosocial environment is sufficient to support treatment feasibility. Rev. 11/07 13

14 Level of Care Guide (Table II) Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP) Level of Care Level of Care Guide (continued) ASAM Description of general criteria Dimension Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP) Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 Patient has no signs and symptoms of withdrawal. If any biomedical conditions are present, they are sufficiently stable to permit participation in outpatient treatment. Patient engages in abuse of family or significant others, and requires intensive outpatient treatment to reduce the risk of further deterioration, or the patient has a diagnosis requiring intensive outpatient monitoring to minimize distractions from recovery. Patients meeting Dimension 3 description require dual diagnosis treatment. Efforts at outpatient level (SA I.1 or MH I.1) have failed to promote recovery, or although the patient is willing to participate, their perspective inhibits ability to make behavior change with repeated structured intervention. The patient has been an active participant at a less intensive level of care, he or she is experiencing an intensification of symptoms, and his or her level of functioning is deteriorating. The patient lacks social contacts so as to jeopardized recovery and/or continued exposure to school, work, or living environment will render recovery unlikely. Rev. 11/07 14

15 Level of Care Guide (Table III) Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening Level of Care Guide (continued) Level of Care ASAM Dimension Description of general criteria Level II: (SA II.5 & MH II.5) Partial Hospital & SA Day/Evening Dimension 1 Dimension 2 Dimension 3 Dimension 4 Dimension 5 Dimension 6 Patient has no signs and symptoms of withdrawal. If any biomedical conditions are present, they are sufficiently stable to permit participation in outpatient treatment, however they may provide distraction from recovery efforts. The patient s mental status history is characterized by a mild to moderate psychiatric decompensation on discontinuation of the drug(s) of abuse. Patients meeting Dimension 3 description require dual diagnosis treatment. Efforts at another treatment level have failed and structured programmatic milieu interventions are not likely to succeed at Level II.1, or, although the patient is willing to participate, their perspective and lack of impulse control inhibits ability to make behavior change with repeated structured intervention. The patient has been an active participant at a less intensive level of care, he or she is experiencing an intensification of symptoms, and his or her level of functioning is deteriorating; or a lack of awareness of relapse triggers creates is a high likelihood of relapse. The patient s family members or significant others who live with the patient are not supportive of recovery goals, and continued exposure to school, work, or living environment will render recovery unlikely. Rev. 11/07 15

16 Referral and Authorization Process There are a variety of procedures in which each party of Project S.A.F.E. is required to follow. In the following section, we will outline what we (ABH) will do, and what DCF and/or the Provider are required to do, in order that our clients receive services in an efficient, professional, and timely manner. Rev. 11/07 16

17 Service Authorization and Referral Process for Covered Services One of Project S.A.F.E. s goals is to ensure that adults involved in the child welfare system have priority access to drug screening, substance abuse evaluations and outpatient services. By definition Priority Access means once contacted with an evaluation referral the provider will offer an evaluation appointment within five (5) business days. If requests are urgent, the provider should attempt to offer an appointment within twenty-four (24) hours. The following section sets forth the general requirements for referrals and service authorization for service types and levels of care. 1. Initial Referral An initial referral is the first time DCF Worker has called ABH Project S.A.F.E. regarding an identified client to make a referral. a. An initial referral must be made to ABH in order for an individual to be considered a Project S.A.F.E. client. b. The DCF Social Worker must obtain a release of information for ABH prior to making the referral. c. A referral will only be accepted from a DCF Social Worker or other DCF designated staff (Supervisor, Area Resource Group, Central Office). d. To make a referral the DCF Social Worker calls the ABH Project S.A.F.E. intake line ( ). e. The DCF worker will be asked a series of questions including which Provider they would like the client to see. f. The Project S.A.F.E. Intake Coordinator(s) will enter the information into the database all information asked, creating a Project S.A.F.E. Client ID number and electronic record. The electronic record will include demographic information, substance use concern as identified by the DCF Social Worker and an initial authorization for the service/services being requested. g. The Project S.A.F.E. intake coordinator will then fax the referral (which also serves as the authorization) to the Project S.A.F.E. Provider. 2. Evaluation: The DCF Social Worker requests an evaluation once the DCF substance abuse screen (DCF form 2110) is completed and there is suspicion that the individuals ability to parent effectively is impaired as a result of substance use. To include a urine drug screen as part of the evaluation the DCF Social Worker should also request one (1) urine drug screen. 1. Prior to making the ABH Project S.A.F.E. referral, the DCF Social Worker will obtain a release of information from the client for Advanced Behavioral Health and the provider. 2. The DCF Social Worker calls the Intake Coordinators at The DCF Social Worker will provide basic demographics, reason for referral and any updated information. 4. Once the Telephonic referral is completed, the Project S.A.F.E. Intake Coordinator will fax the client referral form and substance abuse screening Rev. 11/07 17

18 form [Appendix A] to the Project S.A.F.E. Provider. This serves as an authorization for the evaluation. 5. The DCF Social Worker should fax the release of information to the provider. Providers will be unable to schedule an appointment without a signed release of information. 6. The Provider should verify the client s health insurance using the EDS. If the client has insurance the Provider should submit a claim to both ABH Project S.A.F.E. and the client s health insurance carrier. ABH Project S.A.F.E. is the payer of last resort. 7. The preferred location for conducting evaluations is at the Provider s place of business; in addition the provider is expected to conduct a chain of custody (See glossary of terms) urine screen. 8. Upon completing the evaluation, results should be verbally communicated to the DCF Social Worker within twenty-four hours (one business day). 9. A written clinical summary should follow this verbal communication within five (5) business days. The summary should contain the following minimum information: Demographic information Family composition and history Substance abuse history Trauma history Medical history and current medical status DSM IV TR Diagnostic formulation Drug screen results 10. Upon completion of the evaluation Providers are responsible for faxing the following forms to Project S.A.F.E claims department a. Client Report Form [Appendix B] b. Needs Assessment Form (for females only) [Appendix C] c. TANF Eligibility Form [Appendix D] d. OTR completed if the Provider is recommending IOP or PHP levels of care. 11. The Provider must inform the DCF Social Worker within twenty- four hours when a client fails to show for a drug screen and/or evaluation before rescheduling. It should be decided jointly who will contact the client to reschedule. If a client has a history of no shows with the assigned Project S.A.F.E. Provider, while reasonable efforts should be made to provide priority access, the Provider may apply their agency s policy regarding rescheduling. The appointment has to be rescheduled and the client seen within 45 days of the date of the original referral date. If this does not occur the DCF Social Worker has to make another referral by calling the Project S.A.F.E. Intake Coordinators. 3. Outpatient 1.1 levels of care: There are three (3) basic Outpatient services, which falls under 1.1 levels of care that are reimbursable within Project S.A.F.E. (individual psychotherapy, group counseling, and family counseling). Rev. 11/07 18

19 a. The DCF Social Worker will make a telephonic treatment referral by calling the intake coordinator at the ABH Project S.A.F.E b. The DCF Social Worker will need to provide: i. Release of Information ii. Client Insurance Information iii. Client Social Security Number iv. Results of DCF Substance Abuse Screen v. Basic Demographic Information vi. Reason for Referral c. The intake coordinator will enter the referral information into the Project S.A.F.E. data system and fax the referral. This referral also serves as the authorization for the treatment provider. d. The authorizations will allow the provider to receive reimbursement for the provision of individual, group and /or family/couple counseling treatment. e. The treatment must begin within forty-five (45) days of the start date of the referral. If the client does not attend treatment within the forty-five (45) days of the start date of the referral, then the DCF Social Worker must make a new treatment only referral. The Provider should notify the DCF Social Worker when a referral lapses beyond the 45-day limit to request that the DCF Social Worker call in a treatment only referral. f. The Provider is to notify the DCF Social Worker if the client does not show for their treatment appointment. g. The Provider should regularly report to DCF the course of the client s treatment. 4. IOP: IOP services provides each client with three to four (3-4) hours per day, three to five (3-5) days per week of clinically intensive programming based on an individualized treatment plan. a. IOP services may be recommended based on a bio-psycho-social evaluation that has been completed within six (6) months of the service request. b. The Provider must complete an OTR to ABH via facsimile at The OTR can be downloaded from the following web address: (for process see Appendix E). c. Services will be authorized based on a Utilization Review process d. Clinical staff at ABH will review all OTR information for clinical appropriateness and provider compliance with submission criteria. i. Submission criteria 1. The OTR should be completed in its entirety. 2. The OTR should be submitted prior to admission to the IOP level of care. 3. The Provider should promptly respond to any inquires for supporting clinical information. e. ABH will help to educate treatment providers about clinically appropriate treatment planning and decision-making processes regarding level of care, review OTR within three (3) business days. An OTR will be processed with one of the following four outcomes: Rev. 11/07 19

20 i. Authorization an authorization will be processed, entered into the ABH system and fax authorization notification will be generated and forwarded to the provider ii. Request for Additional Information- the clinician submitting the OTR will be contacted telephonically, with a request for additional information; iii. Administrative Denial a denial letter will be issued based on procedural exceptions; iv. Clinical Denial a clinical denial will be issued based upon a review of clinical information. f. ABH will provide an appropriate appeal process for all adverse determinations. 5. PHP: PHP consists of therapeutic programming with a minimum of four (4) hours per day, at least four (4) days per week, based on a comprehensive and coordinated individualized treatment plan involving the use of multiple concurrent treatment services and modalities. a. PHP services may be recommended based on a bio-psycho-social evaluation that has been completed within six (6) months. b. The Provider must complete an OTR and fax to ABH at The OTR can be downloaded from the following web address: (for process see Appendix E). c. Services will be authorized based on a Utilization Review process d. Clinical staff at ABH will review all OTR information for clinical appropriateness and provider compliance with submission criteria. i. Submission criteria 1. The OTR should be completed in its entirety. 2. The OTR should be submitted prior to admission to the IOP level of care. 3. The Provider should promptly respond to any inquires for supporting clinical information. e. ABH will review the OTR within three (3) business days. An OTR will be processed with one of the following four outcomes: i. Authorization an authorization will be processed, entered into the ABH system and an authorization notification will be generated and forwarded to the provider ii. Request for Additional Information- the clinician submitting the OTR will be contacted telephonically, with a request for additional information; iii. Administrative Denial a denial letter will be issued based on procedural exceptions; iv. Clinical Denial a clinical denial will be issued based upon a review of clinical information. f. ABH will provide an appropriate appeal process for all adverse determinations. 6. Random Drug Screens: Random urine drug screens are defined as two (2) urine drug screens per week for a period of six (6) weeks and should not occur on the same day and time each week. Urine Screens can be requested for clients who are not in treatment if in response to a court ordered request. Rev. 11/07 20

21 a. The DCF Social Worker makes a telephonic referral. This referral results in an authorization for services b. ABH Project S.A.F.E. will authorize 12 random urine screens. c. The screens can be initiated at any time during the next forty-five (45) days. Once the random screens have begun they may continue for a period of no longer than six (6) weeks. d. The Provider is required to collect all urine samples using the chain of custody protocol as indicated on the reverse side of the chain of custody form. e. The Provider, to schedule a random screen, will contact the client asking the client to come in within the next twenty-four (24) hours for a drug screen, provided it is not on a day when treatment services are provided. f. The Provider will verbally communicate all toxicology screen results to the DCF Social Worker within forty-eight (48) hours. Written results should be faxed to the DCF Social Worker within 24 hours of receipt of written correspondence from the lab. 7. Extended Drug Screens (e.g. Opiate Search) a. The DCF worker consults with the SAS to receive authorization for any extended drug screens, once the standard screen has been completed with a positive result. b. If a urine screen is positive for heroin an Extended Opiate Search can be conducted by having the Substance Abuse Specialist or designee of the Substance Abuse Division approve this test by calling the ABH Billing Coordinator at An Extended Opiate Search can differentiate the positive opiate as heroin, hydrocodone, hydromorphone, morphine and oxycodone. c. Once this has been obtained the SAS must call the ABH Billing Coordinator at with client name, ABH number, and verification of approval from the Substance Abuse Specialist. d. The provider will then be contacted by the SAS or DCF social worker notifying of approval. e. The provider will then complete the LabCorp request. f. When results of the extended drug screen are received, the results should be communicated to DCF upon receipt. g. When received, the Provider should forward the specific LabCorp Invoice to ABH via mail 213 Court Street, Middletown, CT or fax to Hair Testing: Hair testing is utilized to determine the substance use/abuse history of a client up to three (3) months prior to the sample collection. This standard test will indicate whether a client has used any of the following substances during that period: Cocaine Opiates PCP; Methamphetamine Marijuana/THC Rev. 11/07 21

22 In addition, when a positive result is determined by the standard hair test results, a multisectional test can be performed per request of the referring DCF Social Worker. b. The DCF Social Worker will discuss the necessity and request for approval with the Substance Abuse Specialist and/ or supervisor or designee in the Substance Abuse Division. c. The DCF Social Worker then calls the ABH Intake Coordinator at for the hair test referral and provides the following information: i. Name of person authorizing the test (SAS or designee has to approve before the referral is called into ABH Project S.A.F.E.) ii. Name and ABH number of the client d. ABH Project S.A.F.E. identifies the provider performing the test, enters an authorization and faxes notification to that provider. e. The Provider will complete a Standard Test Request Form (TRF-ST-004) and complete a hair test. f. The Provider should collect a sufficient quantity of hair (about 2 inches in length and 50 strand of hair cut about ¼ inch from the scalp). If the client has short hair more hairs will be need to meet the collection needs. g. The hair testing facility will complete a 5-panel hair toxicology screen (Cocaine, Methamphetamine, Opiates, PCP, Marijuana). Results will be reported within 2-6 business days. h. If there are positive results reported from the Standard Hair Test Screen, the Provider can call the testing facility (Psychmedics at ) to request a complete sectional analysis. It is important to clarify that you are calling about an ABH client and requesting the additional testing. Psychmedics will invoice. ABH directly for additional testing. Rev. 11/07 22

23 Referral and Authorization Process (CHART) Type of Service/Level of Care Information Needed From DCF Information Need from the Provider Information needed or provided by ABH Authorization Requirements Evaluation (up to 90 minutes) Outpatient (Individual, Group, Family/Couples) Release of Information from the client. Telephonic referral to ABH. Telephonic referral if treatment only referral or if there has been a 45 day lapse from the initial referral call Results and recommendations forwarded to DCF within five (5) business days. Client Reporting Form, TANF, and Needs Assessment for women. Verify client s insurance, check for existing referral IOP An OTR needs to be submitted before services rendered PHP An OTR needs to be submitted before services rendered Urine Drug Screen Telephonic referral Random screens have to be done within six (6) weeks Extended Drug Screens Hair Test SAS authorization SAS authorization, Court Order and/or Program Supervisor authorization LabCorp invoice via fax for reimbursement See Hair testing procedure Client Referral Form, which serves as the authorization for the evaluation. Basic demographic information and substance abuse information from the DCF worker. Random screens are included. An evaluation has been conducted within the last six (6) months. Utilization Review of OTR Utilization Review of OTR Will authorize 12 units to be conducted within six (6) weeks. Reimbursement for pre-authorized test Set up a referral upon telephonic referral Telephonic call from DCF There has to be an evaluation that has been completed within the last six (6) months. An open referral must exist. OTR faxed to ABH directly. OTR faxed to ABH directly. Telephonic referral by DCF worker needs to be called in prior to services Telephonic authorization Telephonic authorization Rev. 11/07 23

24 Reimbursement Protocol There are a variety of procedures that each party involved in ABH Project S.A.F.E. is required to follow. In the following section, we will outline what we (ABH) will do, and what DCF and/or the Provider are required to do, in order that client services are reimbursed. Rev. 11/07 24

25 Provider Credentialing Project S.A.F.E. services will be provided by agencies licensed by the Department of Public Health to provide outpatient substance abuse services and that have an agreement with ABH. Professionals within an agency who hold one of the following qualifications will be eligible to conduct evaluations: Certified Alcohol and Drug Counselor (CADC) Certified Alcohol Counselor (CAC) Licensed Alcohol and Drug Counselor (LADC) Masters or doctoral level clinician with at least two years of experience in the treatment of substance abuse Connecticut licensed Registered Nurse with at least two years of experience in the treatment of substance abuse Staff with backgrounds other than those listed above will be considered on a case-by-case basis and approved by the ABH Project S.A.F.E. Program Manager or designee. All non-certified or nonlicensed evaluators must be supervised by a licensed masters or doctoral level clinician. Reimbursement Project S.A.F.E. provides reimbursement for all authorized evaluations, outpatient treatment services, drug screens/hair tests, and court costs. ABH Project S.A.F.E. offers providers a web based electronic system to submit claims electronically; ABH Project S.A.F.E. encourages providers to make use of this system. ABH offers training twice annually on how to submit claims using the electronic system. ABH Project S.A.F.E. will make itself available to providers for assistance or individual trainings on an ad hoc basis. ABH Project S.A.F.E. is the payer of last resort and as such clients are expected to use their insurance plan when receiving Project S.A.F.E. services. Providers will be reimbursed the difference between what the insurance company pays, and the approved ABH reimbursement rate. Fee schedules are furnished to provider groups as part of the initial and annual contracting. Reimbursement Procedures: Evaluation Treatment IOP and PHP Drug Screens o Urine Screens o Extended Drug Screens o Hair Test Court Appearances Rev. 11/07 25

26 Reimbursement for Evaluation DCF Responsibilities Provider Responsibilities The DCF Social Worker will need to call ABH Project S.A.F.E to make an evaluation referral. The DCF Worker will need to provide the following information: Release of Information Client s Insurance Information Client s Social Security Number Results of DCF Substance Abuse Screen Basic Demographic Information It is important to remember that an evaluation referral includes a referral for treatment if the treatment services begin within 45-days of the date of the referral. **************************************************************** The Evaluation provider needs to be aware of any existing referrals. Appointments should be provided within the priority access guidelines, if the Provider is unable to do so, they should notify ABH Project S.A.F.E. The provider needs to contact the DCF Social Worker with verbal results of an evaluation within 24 hours, and with written results within 5 days. A referral will lapse if no service is provided within a forty-five (45) day limit. To determine if the Referral has lapsed, the Provider will look on the Client Referral Form [Appendix A] review the service(s) requested end date. The evaluation needs to be conducted before this date; if not the Provider should request that the DCF Social Worker call ABH Project S.A.F.E. to make a new referral. The Provider needs to complete the following information and submit to the ABH claims department: Client Report Form [Appendix B] For women only the Needs Assessment Form [Appendix C] TANF Eligibility Screening Form [Appendix D] The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame will be denied reimbursement for untimely filing. ABH Project S.A.F.E. Will If there is a correction required on any submitted claim, the Provider has 90 days from the service date to correct the claim. **************************************************************** ABH will fax the referral information to the Provider when a DCF Social Worker makes an evaluation referral. This referral information serves as the authorization. [Appendix A] ABH will maintain an electronic record of every referral, which will allow reimbursement for an evaluation provided. Rev. 11/07 26

27 Reimbursement for Treatment DCF Responsibilities Provider Responsibilities The DCF Social Worker will need to call ABH Project S.A.F.E to make a treatment only referral. The DCF Social Worker will need to provide the following information: Release of Information Client s Insurance Information Client s Social Security Number Results of DCF Substance Abuse Screen Basic Demographic Information It is important to remember that if treatment begins within 45 days of the evaluation referral start date no treatment referral needs to be called in by the DCF worker. ******************************************************************* The Treatment provider needs to be aware of any existing referrals. If the treatment services begin within 45 days of the start date of the evaluation referral, the Provider can submit claims as described in the claims submission portion of this document. If a referral lapses because it is beyond the 45 day limit, the provider should contact the DCF Social Worker and request that he or she call in a new referral. The provider should communicate the course of client treatment by contacting the DCF Social Worker regularly. Providers who create a treatment plan which recommends IOP or PHP must complete an OTR (see following reimbursement section). The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame will be denied reimbursement for untimely filing. Providers should verify the client s insurance and indicate this information in the claims submission process. If a client does not have insurance a special exception can be granted. See Special Exception procedure (page 29). Treatment-only referrals can be made under the following circumstances: Treatment-only referrals following an acute care episode; Treatment-only referrals resulting from the need to transfer a client from one provider to another; Treatment-only referral following a lapsed forty-five (45) day referral. In every case it is required that an evaluation has been completed (within the previous six (6) months) prior to the DCF Social Worker making a treatment-only referral through contacting the Project S.A.F.E. Referral Hotline at ABH. ***************************************************************** Rev. 11/07 27

28 ABH Project S.A.F.E. Will ABH Project S.A.F.E. will fax the referral information to the Provider when a DCF Social Worker makes the treatment referral. ABH Project S.A.F.E. will fax the Client Referral Form with Treatment Only indicated in the service(s) requested section. (Appendix B) ABH will maintain an electronic record of every referral, which will allow reimbursement for treatment. A separate referral for urine screens is not required under a treatment only referral. Chain of custody random urine screens will be reimbursed by ABH under the treatment only authorization called in by the DCF worker. Rev. 11/07 28

29 Reimbursement for IOP or PHP Levels of Care DCF Responsibilities Provider Responsibilities Ensure that all necessary information is available to both the treatment provider and ABH. ************************************************************ IOP and PHP levels of care are authorized based upon a process of Utilization Review (UR). To engage in this process the Provider must submit an Outpatient Treatment Request Form (OTR) [Appendix E]. The OTR form must be completely filled-out, with the necessary demographic and clinical information prior to admission to the IOP or PHP levels of care. An OTR form needs to be completed prior to the expiration or completion of services previously authorized. Any subsequent OTR forms should be completed with new clinical information and an updated treatment plan. The provider is required to respond promptly to any inquiries for supporting clinical information. Once a it has been determined that the client is no longer in need of IOP or PHP services a Discharge Notification Form [Appendix F] needs to be completed. ABH Project S.A.F.E. Will The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame will be denied reimbursement for untimely filing. IOP and PHP services can also be denied if the client does not meet clinical criteria. ************************************************************* Help educate treatment providers about clinically appropriate treatment planning, and decision-making processes regarding level of care decisions as requested. Receive and process Outpatient Treatment Requests (OTR) for IOP and PHP levels of care through Utilization Review. In order to assure that the patients who require IOP and PHP levels of care, these services are authorized based upon a process of Utilization Review (UR). While no effort is being made to restrict access to these levels of care, the goal of UR ensuring that limited treatment funding provides treatment for those clients with clinically appropriate need. Provide a three-day turnaround time on authorization decisions, with access to urgent authorizations when clinically necessary. Provide an appropriate appeal process for all adverse determinations. (See Appeals Process page) Maintain a copy of the OTR for download at the following web address: https://www.abhct.com Rev. 11/07 29

30 Reimbursement for Hair Testing DCF Responsibilities Provider Responsibilities Hair test can be requested by the DCF Social Worker to determine if a client has abused a substance over the past 90 days. Hair testing is useful for obtaining historical use within a 90-day period. To request a hair test and receive reimbursement the DCF Social Worker will contact the Substance Abuse Specialist in their respective offices for approval. Once this approval has been granted DCF should contact ABH Project S.A.F.E. ************************************************************ The provider is required to collect a sufficient sample for a hair test in accordance with standards for hair testing as specified in the training. The provider then submits the sample, with a request for a standard screen to Psychemedics. If the results are positive the provider can request a multi-sectional testing of the positive result, by calling Psychemedics at their toll-free number and requesting a multi-sectional be completed. This multi-sectional does not require the client to return to the office and will not be reimbursed by ABH. Results should be discussed with the DCF Social Worker through telephone contact as soon as possible. ABH Project S.A.F.E. Will The Provider must submit claims for reimbursement no more than 30 days following the date the service was provided. Claims submitted beyond this time frame will be denied reimbursement for untimely filing. ************************************************************* ABH will serve as the coordinator of Hair testing requests, and as the conduit for information between Psychemedics and other parties involved. ABH will help expedite procedures whenever possible, and will provide a forum for annual training for any provider who is interested. ABH will ensure that Psychemedics is meeting the criteria for timely reporting of results, through a monitoring program. ABH will provide reimbursement to providers, which includes an administrative fee related to collection and submission of the sample to LabCorp, and the actual cost that LabCorp invoices the provider for completion of urinalysis. Rev. 11/07 30

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