Mental Health. Mental Retardation of Tarrant County. Mental Health. Resiliency and disease management clinic. Provider Manual

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1 Mental Health Mental Retardation of Tarrant County Mental Health Resiliency and disease management clinic Provider Manual

2 SEPTEMBER,2010

3 Table of Contents INTRODUCTION..1 MISSION STATEMENT& VALUES..2 ORGANIZATIONAL STRUCTURE..3 IMPORTANT POINTS TO REMEMBER...3 REFERRAL AND AUTHORIZATION PROCESSES..4 SERVICES DOCUMENTATION... 8 CLAIMS & BILLING REPORTING REQUIREMENTS MONTHLY REPORT STAFF TRAINING CREDENTIALING AND CLINICAL SUPERVISION MEDICATIONS LA QUALITY MANAGEMENT/CONTRACT MONITORING PROVIDER PROFILE COMPLAINTS SANCTIONS, APPEALS AND CONTRACT TERMINATION REFERENCES... 49

4 Introduction W elcome to Mental Health Mental Retardation of Tarrant County (MHMRTC). We are pleased to recognize you as a member of our Provider Network and look forward to enjoying a long and mutually satisfying contractual relationship with you. The purpose of this Provider Manual is to educate you about the policies and procedures of MHMRTC. We ask that you read this material carefully and discuss any questions you may have with our Director of Contracts Management/Provider Relations, Kevin McClean, at (817) MHMRTC is staffed by a team of highly dedicated professionals experienced in managed care and the provision of services for persons who are diagnosed with mental illness. MHMRTC is dedicated to providing high quality, innovative, and cost-effective management of mental health services. Our philosophy is propelled by a strong commitment to service excellence supported by management flexibility and accountability. Our on-going objective is to continually refine our system so that we can excel in the delivery of quality services as we balance the best interests of our consumers, providers, and employees. MHMRTC clearly understands that open communication must exist between our service providers and our organization in order for us to be able to provide individuals in our community with the best possible care. We, therefore, invite you to share your perceptions, needs, and suggestions with our Director of Contracts Management/Provider Relations, who will also, from time to time, ask you to respond to surveys to help us identify other opportunities to improve our services and to assess your satisfaction as a member of our provider network. We will do all that we can to support your entry into our system and assure that your continued participation in our network will be beneficial for all concerned. In this Provider Manual, references may be made to consumers, clients, and covered individuals. All of these terms are to be considered interchangeable. Other references that are used interchangeably are MHMRTC and Local Authority (LA), and DSHS and State Authority (SA). 1

5 Mission Statement & Values Mission Statement of MHMR of Tarrant County: To enhance the mental health and intellectual development of people in our community. Values Each person is respected and valued. Services are developed around the individual needs, values, and opinions of each person served. Families are valued and respected for their critical importance in a person s support system and are given the opportunity to have an active role in treatment planning and the delivery of services. Success is demonstrated in terms of outcome for each person served. Services enhance dignity through participation and choice. Services encourage and support growth, independence, and integration into the community. Quality services are provided in a safe, ethical, and cost effective manner, and provide the best value to the person served. Programmatic and administrative best practices are recognized and valued. A seamless system of services is realized through the coordination and collaboration of providers in the community. 2

6 Organizational Structure The organizational structure of MHMRTC includes the Mental Health and Mental Retardation Community Advisory Committees. These two committees are composed of individuals from the community, including consumers, who have a vested interest in assuring that quality services are readily available to our consumers. The committees are empowered to provide input into the planning process that will lead our organization into the future. Both of the committees report to our Board of Trustees. Our Chief Executive Officer is accountable to our Board of Trustees. The Deputy Chief Executive Officer directs the Authority component of our organization and is accountable to our Chief Executive Officer. Chiefs who report directly to the Deputy Chief Executive Officer direct both Mental Health and Mental Retardation Services. There are three Chiefs who oversee the administrative duties of our organization, which includes Information Systems, Finance, and Human Resources and are accountable to our Chief Executive Officer. These areas provide support services to the Authority and to MHMRTC providers. Currently, MHMRTC has providers in the areas of Mental Health Services, Mental Retardation Services, Addiction Services, and Early Childhood Intervention Services. We anticipate continued growth in expanding our service providers from the community. Important Points to Remember Provider s Responsibilities It is the provider s responsibility to render services to MHMRTC consumers in accordance with the terms of the contract. The provider is required to render these services to MHMRTC consumers in the same manner, adhering to the same standards, and within the same time availability as offered to all other consumers. MHMRTC does not guarantee that a MHMRTC consumer or any number of MHMRTC consumers will utilize any particular provider. Each consumer is given information regarding all providers in the provider network and then makes the choice of provider(s). Providers are required to immediately call MHMRTC s Risk Management Department at (817) and to contact each consumer s MHMRTC Designated Staff Liaison to report occurrences of the following: Client deaths Suicide attempts Serious injuries injuries which require medical care Serious medication errors Adverse Drug Reactions Allegations of homicide, attempted homicide, threat of homicide with a plan 3

7 Incidents of restraint or seclusion Confirmed abuse, neglect, or exploitation Discovered pharmacy errors Providers are required to inform consumers that they have the right to report any complaints about the services they are receiving to the Consumer Complaint Reporting Line at: (817) or (toll free) All provider complaints and/or suggestions are to be communicated to the Director of Contracts Management/Provider Relations at (817) All suspicions of client abuse are to be reported to the Texas Department of Family and Protective Services at or Referral and Authorization Processes Referral Process All referrals to Provider will come from the MHMRTC Licensed Practioner of the Healing Arts (LPHA) after the LPHA determines that a Covered Individual meets medical necessity criteria for the delivery of Resiliency and Disease Management services and authorizes the delivery of those services. Authorization for services may only be made by an LPHA from MHMRTC (c )(2) (2) (30) Determination that there is a medical necessity for Medicaid MH rehabilitative services for the individual has been made by an LPHA. Medical necessity--evidenced by LPHA signature on the DMN form E-019 or the LOC-A printed from WebCARE. There is no guarantee that Provider will be used by a Covered Individual or any number of Covered Individuals. The LPHA will offer the Covered Individual a choice of providers from the list of contracted Providers. Covered Individuals will document their choice and are allowed to change Providers. Provider will not engage in case finding or otherwise locating individuals to receive rehabilitative services and is prohibited from offering any gift with a value in excess of $10 to potential clients and from soliciting potential clients through direct-mail or by telephone. 4

8 Authorization of Services When a client is identified as needing Resiliency and Disease Management services and agrees to participate, the MHMRTC LPHA, will authorize the type and amount of service to be provided during the first 90 days. Once a Provider has been selected by the client, an Authorization letter will be generated and sent (typically faxed) to the selected Provider along with the client s diagnosis and a copy of the Rehabilitative Service Plan. The Authorization Letter will include the Covered Individual s name, the date services are authorized to begin, the type and quantity of services authorized, the lapse date for the Authorization (by when the services must be provided or will no longer be authorized), and the Authorization Number. Provider will not be reimbursed for services not pre-authorized with an Authorization Number. The LPHA is responsible for following up with the Provider within 5 to 15 working days from the referral to confirm the Provider was able to contact the client. The Provider must develop a Treatment Plan for the Rehab services and begin services. The treatment plan needs to be completed within 10 days of the auth. The plan needs to meet the following requirements: ( e ) a (2) Treatment plan (Present) developed within 10 day after authorization is obtained (TP signed within 10 days of LOC-A) At a minimum a staff member credentialed as a QMHP-CS must complete ( e )(1) (e) (1) (A)-(G) (e) (1) (A) (e) (1) (B) (e) (1) (C) (e) (1) (D) (e) (1) (E (e) (1) (F) (e) (1) (G) and sign the plan Description of A presenting problem, B needs related to MI, C strengths, D preferences, E assessment, Physical health, G COPSD complete A description of the presenting problem section A A description of the individuals strengths C A description of the individuals needs arising from the mental illness section B/ E related needs A description of the /physical health issue/copsd section G and F A description of the expected outcomes An expected date for recovery goals to be achieved List of resources for recovery ( last section of plan after signatures or brochure) List of types of services (services to be delivered must be checked or written (e) (1) (a) (3) out code or name of service) (H) (A) (e) (1) (H)(i) List of strategies to be implemented by staff to achieve goals (Strategy statement listed) (e) (1) (H)(ii) The frequency, number of units, and duration of each service to be provided is present (e) (1) (H)(iii) The credentials of staff providing the service are present (e) (2) (A) Goals address individual s needs, preferences, experiences, and cultural background (e) (2) (B) Goals must address the individuals COPSD issue and or physical health disorder (e) (2) (C ) Goals are expressed in overt, observable actions of the individual (e) Goals must be objective and measurable - using quantifiable criteria. 5

9 (2)(D) (e) (2)(E) (e) (2) (A) (e) (2) (B) (e) (2) (C ) (e) (2)(D) (e) (2)(E) (e) (3) (f) (1) (A) (f) (1) (B) (f) (1) (C) (f) (1) (D) (d) (1) (A) Goals reflect individual autonomy, self direction, and desired outcomes. Objectives address individual s needs, preferences, experiences, and cultural background. Objectives address the individuals COPSD issue or physical health disorder. Objectives are expressed in overt, observable actions of the individual. Objectives are objective and measurable using quantifiable criteria. Objectives reflect individual autonomy, self direction, and desired outcomes. Copy of plan provided to the individual or explanation of reason why copy is not given. REVIEW Review plan prior to requesting authorization for the continuation of services documented before 475/473 Review plan in its entirety, at least every 90 days. Determine if the plan is addressing needs of individual. Narrative comments by staff and client. Document progress on all goals and objectives and any recommendation for continuing services, change for services, discharge from services. Check box's marked. Record documentation must be legible to others (other than author) Record must have Medicaid # and client's name on each page of significant documents, effective 11/1/99 6

10 Reauthorization of Services Local Authority LPHA is responsible for reauthorization and determination of medical necessity. As part of the Determination of Medical Necessity (DMN) oversight required by the Medicaid Rehab guidelines, the Local Authority LPHA will determine medical necessity of services outlined in the Provider s Treatment Plan which is then reviewed at least every ninety (90) days. To ensure rehab services maintain a valid authorization status, at least two (2) weeks prior to the lapse of the Treatment Plan, Provider should review the client s Treatment Plan, reassess the client, and request reauthorization of the current Service Package or authorization of a Service Package that will meet the client s needs. The Provider will receive an Authorization Letter for continued services which will include an Authorization Number specific to the Covered Individual, the type and amount of service authorized, and the dates during which the services are authorized. Services must be authorized in this manner prior to delivery of services for the Provider to be paid. Providers can confirm authorized status in WebCARE Report Screen #251 for adults. Occasionally, a Covered Individual will drop out of services or cannot be located by the LPHA to reauthorize services. If such an individual presents with the Provider for services, Provider must reassess the client and request authorization the same day via entry in WebCARE. When the Level of Care Recommended (LOCR) equals the Level of Care Authorized (LOCA), the assessment date is used as the effective date of authorization. When the LOCR does not equal the LOCA, the WebCARE data entry or add date is used as the effective date of authorization. Thus, when the LOCA is different from the LOCR, the date the assessment is entered into WebCARE is the earliest that billable services will be covered unless being reasssed during the already authorized period prior to assessment and authorization expiration. If a change in level of service is subject to Fair Hearing procedures, (reductions and terminations of level of care), the authorization date is delayed days from the assessment date. (See Automatic Authorization Agreement and TAC 357, Subchapter A Uniform Fair Hearing Rules.) NOTE: Review of Plans and reauth- we currently as the provider complete a new plan when a client is new, autoclosed, or changes packages. Reviews are to be done at least every 90 days. Additionally the review occurs prior to request of authorization. The rule explicitly requires this. REVIEW Review plan prior to requesting authorization for the continuation of services. (f) (1) (A) 3403 documented before 475/ Review plan in its entirety, at least every 90 days. (f) (1) (B) (f) (1) (C) (f) (1) (D) (d) (1) (A) Determine if the plan is addressing needs of individual. Narrative comments by staff and client. Document progress on all goals and objectives and any recommendation for continuing services, change for services, discharge from services. Check box's marked. Discharge from ServicesProvider must consult with the LPHA and obtain approval prior to discharging a Covered Individual from rehabilitative services. Discharge requests will comply with MH- 014, Mental Health Services Discharge Process. 7

11 Services Covered Services Covered Services are those services which are determined by Local Authority to be Medically Necessary Services when authorized as part of the current UA-RDM assessment and treatment plan of the Covered Individual approved by a Licensed Practitioner of the Healing Arts. Provider is prohibited from providing more than one rehabilitative service to an individual at the same time and on the same day. The services proposed to serve any individual in the authorized level of care of Service Package are: reasonable and necessary for the diagnosis or treatment of a mental health disorder or a cooccurring psychiatric and substance use disorder (COPSD) in order to improve or maintain the individual s level of functioning; in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care; furnished in the most clinically appropriate available setting in which the service can be safely provided; provided at a level that is safe and appropriate for the individual s needs and facilitates the individual s recovery; and could not be omitted without adversely affecting the individual s mental or physical health or the quality of care rendered (Reference: Texas Administrative Code Definitions, (39) Medical necessity). Diagnosis (b) ( c) Client is an adult with severe and persistent mental illness or a child or adolescent with a serious emotional disturbance. MI documented covering the time services were rendered. Diagnosis should be completed at least one time annually by licensed staff acting within the scope of their license- all 5 axis should be addressed and should meet DSHS contract requirement. Primary axis must be indicated. The diagnosis is batched to CARE along with the registration information as it is entered into CMHC. If new generation medication is prescribed the data must be recorded and provided so that it can be reported to the DSHS in the weekly batch. Data must be entered in a timely manner according to the attached procedure. Documentation 8

12 Provider must maintain records necessary to verify services delivered and billed to MHMR of Tarrant County. Provider must additionally maintain records including the following: 1. Names of all Covered Individuals enrolled with Provider 2. Evidence of licensure, certification or accreditation, as required 3. Evidence of Life Safety Code or ADA inspection and compliance, if applicable 4. Evidence of insurance coverage 5. Evidence of criminal history checks of staff 6. Evidence of required staff training 7. If Covered Individuals are paid by Provider, evidence of compliance with Department of Labor (DOL) regulations regarding salaries and pay 8. Doctor s orders and medication records if medications are administered by Provider staff 9. Fire Marshall inspection and results of fire drills 10. Evidence of annual health department inspection for day programs which serve or prepare food for 10 or more Covered Individuals. Provider will retain records for a minimum of seven (7) years. Provider will receive, store, process, or otherwise deal with client information, if any, accessed or generated during services in compliance with Chapter 414, Subchapter A, Client Identifying Information, of Title 25 of the Texas Administrative Code. Service Documentation The Provider is responsible for documenting all services. All service documentation must meet all Mental Health Community Services Standards, and Medicaid Rehabilitation documentation requirements. Registration: client must be registered in CARE. Diagnosis: All 5 axes completed, signed and dated by LPHA at least annually and primary axis indicator identified. Assessments The Provider is responsible for ongoing assessments of the Covered Individual s need for and response to specific rehabilitative services. These assessments occur in collaboration with the Covered Individual and, minimally, identify the following: the Covered Individual s recovery goals; the Covered Individual s changing clinical needs the Covered Individual s natural supports and current use and benefit from those supports; and the demands and adaptability of the Covered Individual s chosen environments (a) (2) (d) (1)(A) a 1 (A) Obtain authorization from the department (DSHS) (doc in CMHC or WebCARE) 9

13 , (b) (2) (B) Services delivered must be within service package authorized. Assessments must meet DSHS contract reqs for frequency and content by properly credentialed staff. QMHP every 90 days must be entered in a timely manner. Treatment Plan Requirements The Provider is responsible for developing a Treatment Plan with goals and objectives for the client which must conform to the standards of the Mental Health Community Services Standards, Texas Administrative Code 412 G, section and must be developed within ten (10) working days from the initial authorization. Treatment Plans must be signed by the assigned Provider staff and the client and a copy provided to the LPHA upon request. Treatment Plans must, at a minimum, be reviewed and updated every ninety (90) days, or more often if clinically indicated. Treatment plan (Present) developed within 10 day after authorization is obtained (TP signed within 10 days of LOC-A) At a minimum a staff member credentialed as a QMHP-CS must complete and sign the plan Description of A, B, C, D, E, F, G complete A description of the presenting problem section A A description of the individuals strengths C A description of the individuals needs arising from the mental illness section B/ E related needs A description of the /physical health issue/copsd section G and F A description of the expected outcomes An expected date for recovery goals to be achieved List of resources for recovery ( last section of plan after signatures or brochure) List of types of services (services to be delivered must be checked or written out code or name of service) List of strategies to be implemented by staff to achieve goals (Strategy statement listed) The frequency, number of units, and duration of each service to be provided is present. The credentials of staff providing the service are present. Goals address individual s needs, preferences, experiences, and cultural background. Goals must address the individuals COPSD issue and or physical health disorder. 10

14 Goals are expressed in overt, observable actions of the individual. Goals must be objective and measurable - using quantifiable criteria. Goals reflect individual autonomy, self direction, and desired outcomes. Objectives address individual s needs, preferences, experiences, and cultural background. Objectives address the individuals COPSD issue or physical health disorder. Objectives are expressed in overt, observable actions of the individual. Objectives are objective and measurable using quantifiable criteria. Objectives reflect individual autonomy, self direction, and desired outcomes. Copy of plan provided to the individual or explanation of reason why copy is not given. Treatment Plans must, at a minimum, be reviewed and updated every ninety (90) days, or more often if clinically indicated. Review plan prior to requesting authorization for the continuation of services documented before 475/473 Review plan in its entirety, at least every 90 days. Determine if the plan is addressing needs of individual. Narrative comments by staff and client. Document progress on all goals and objectives and any recommendation for continuing services, change for services, discharge from services. Check box's marked. Record documentation must be legible to others (other than author) Record must have Medicaid # and client's name on each page of significant documents, effective 11/1/99 Progress Notes Progress Notes must be completed for all services delivered, and must reflect the service that took place, client behaviors, situational stressors, needs, issues that arise, and the individual s progress or lack of progress towards the anticipated service outcome. Progress notes should convey clinically relevant detail about the client by documenting: 1. the affect, attitude, and behaviors of the individual s participation 2. positive or negative symptoms of their mental illness observed, (or when asked) 3. positive or negative side effects of their medication taken as observed, (or when asked) 4. any clinically relevant issues that arise during the course of service delivery 5. progress (or lack of progress) toward the desired objectives or goal; and 6. in terms that documents evidence of medical necessity by a. maintaining or improving client functioning; b. in the clinically most appropriate setting services can be safely provided; 11

15 c. provided at a safe and appropriate level for the individual s needs and facilitates the individual s recovery; and d. cannot be omitted without adversely affecting the individual s mental or physical health or the quality of care rendered (TAC (39) Medical Necessity). Progress notes must conform to the Medicaid billing requirements and the standard of the MH Community Services Standards, in : It is against the rules to reimburse for travel. REQUIRED IN EVERY REHAB NOTE: Progress note present (1) a (1) Client's name/ recipient (3) (a) (4) Service date (4) (a) (5) Duration (Stop/Start Time) (5) (a) (6) Location/Setting (I) Client present and awake (2) a (2) Type of service provided is supported by sac used (9) (a) (3) The specific skill trained on and method used to provide the training is documented (8) (a) (1) Service is face to face to individual or primary care giver of child adolescent (13) (a) (7) Provider signature and date (13) (a) (7) Credentials of provider (6) (b) (4) (A) A summary of the activities that occurred; (7) (b) (4) (B) (11) (14) ( (10) Additionally per service type (b) (4) The modality of service provision (i.e. one-to-one or group); The treatment plan goal's that was the focus of the service; and The treatment plan objective's that was the focus of the service listed on note or written out. Any pertinent event or behavior relating to the individuals treatment which occurs during the provision of service is documented within the note (b) (4) (D) Status/progress toward treatment Goals (d) (a) (1) Service Provided was provided in excess of LOC-A The title of curriculum being used associated with rehab services only (b) (1) (A) The outcome of the individual's crisis; 12

16 b (1) (A) (b) (2) (b) (3) If the service is a crisis - Medical necessity must be determined within 2 business days after the provision of crisis services Medication Training & Support Services Applies to Children For medication training and support services and skills training and development services, the name of the primary caregiver or LAR to whom the service was provided, if applicable; Medication Related/Psychosocial services must be provided by licensed medical personnel ( Dr, PA, RN, LVN, pharmacist) Psychosocial rehabilitative coordination services (b) (3) (A) A description of the coordination service provided; (b) (3) (B) If the service involves face-to-face or telephone contact, the person with whom the contact was made; and (b) (3) (C) The outcome of the service. NON REIMBURSABLE ACTIVITIES If group service code, Adult group size must be more than 1 and less than (16) clients Children's groups 2 staff up to 6 kids (2) (B) A Medicaid MH rehab service that is not auto's in accordance with Service code used is upcoding Service is a duplicate service (1) Service is provided in excess of amount auth'd Department will not reimburse for more then: (2) (A-D) A 2 hrs per day med training (2515,2516) B 4 hrs per day psychosocial rehab (2919) C 4 hrs per day rehab counseling/therapy (2921) D 4 hrs per day skills train/dev (2923, 2924) The cost of the following activities are included in the Medicaid MH rehabilitative services reimbursement rate(s) and may not be directly billed by the Medicaid provider: (a) (2) (A) (a) (2) (B) (a) (2) (C) Developing and revising the treatment plan and interventions that are appropriate to an individual's needs (3403) Staffing and team meetings to discuss the provision of Medicaid MH rehabilitative services to a specific individual; Monitoring and evaluating outcomes of interventions, including contacts with a person other than the individual (a) (2) (D) Documenting the provision of Medicaid MH rehabilitative services (44) (a) (2) (E) A staff member traveling to and from a location to provide Medicaid MH rehabilitative services (7) (a) (2) (G) Administering the uniform assessment (405,406) 13

17 Services incidental to another service If group service code, group size must be more than 1 and less than 9 clients (2) (B) A Medicaid MH rehab service that is not auth'd in accordance with

18 Using the Web Interface Claims & Billing Gateway Portal User s Manual 1. Access to the website can only be granted by going through the MHMRTC IT department. To obtain a user ID and password contact the MHMRTC Director of Contracts Management/Provider Relations at or 2. Finding the Website 3. User Login Go to web address https://gateway.mhmrtc.org/ Enter your assigned user ID and password. Click on the Log In button. 15

19 4. If you have logged in incorrectly, it will display the message Null User and refresh the page until you enter the correct username and password. Please contact IT if you do not have the correct log in information. 5. If you have logged in correctly, the following service entry screen will display. 6. Understanding Data Entry Requirements A grid of text fields is displayed to represent data for one encounter. All fields are required unless otherwise specified. a. Prov ID Enter the 4 character provider identifier assigned by MHMR. If you logged in as a provider, this field will automatically default to your ID. If you have two provider IDs, make 16

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