CLINIC, REHABILITATION, TARGETED CASE MANAGEMENT OPTIONS AND BHHF CONTRACT PROVIDERS

Transcription

1 APS UTILIZATION MANAGEMENT GUIDELINES West Virginia MEDICAID, CLINIC, REHABILITATION, TARGETED CASE MANAGEMENT OPTIONS AND BHHF CONTRACT PROVIDERS APS Healthcare, Inc.- West Virginia

2 West Virginia Clinic, Rehabilitation, and Targeted Case Management Options AND BHHF Services for Bureau for Behavioral Health Services Contract Providers Table of Contents APS West Virginia Medicaid ASO Definitions... 8 Registration Service Tier 1 H2011 Crisis Intervention BH496 Crisis Phone Call BH497 Involuntary Commitment Linkage Service BH498 Involuntary Commitment Certification Service H0031 Mental Health Assessment by a Non-Physician T1023 HE Screening by Licensed Psychologist Psychological Testing with Interpretation and Report Developmental Testing: Limited Psychiatric Diagnostic Interview Examination Pharmacological Management H2010 Mental Health Comprehensive Medication Services H0032 Mental Health Service Plan by Non-Physician H0032 AH Mental Health Service Plan Development by Non-Physician- Psychologist Participation G9008 Physician Coordinated Care Oversight Services Initial Registration (Tier 1), Tier 2 Continued Stay H0036 Community Psychiatric Supportive Treatment H0004 HO Behavioral Health Counseling, Professional, Individual H0004 HO HQ Behavioral Health Counseling Professional, Group APS Healthcare, Inc.-WV 2

3 West Virginia Clinic, Rehabilitation, and Targeted Case Management Options AND BHHF Services for Bureau for Behavioral Health Services Contract Providers Table of Contents Tier 2 Services H0004 Behavioral Health Counseling, Supportive, Individual H0004 HQ Behavioral Health Counseling, Supportive, Group H0032 AH PP Mental Health Service Plan Development by Non-Physician- Psychologist Participation G9008 PP Physician Coordinated Care Oversight Services Case Consultation T1017 Targeted Case Management Service Tier 3 Services T1017 CM Targeted Case Management Service H0215 Comprehensive Community Support Services H2012 Day Treatment H2012 MR Day Treatment H0040 Assertive Community Treatment (ACT) H2014 U4 Skills Training and Development (1:1 by Paraprofessional) H2014 U1 Skills Training and Development (1:4 by Paraprofessional) H2014 HN U4 Skills Training and Development (1:1 by Professional) H2014 HN U1 Skills Training and Development (1:4 by Professional) H2019 HO Therapeutic Behavioral Services- Development H2019 Therapeutic Behavioral Services- Implementation H0019 U1 Residential Children s Services Level I H0019 U2 Residential Children s Services Level II H0019 U3 Residential Children s Services Level III H0019 U4 Crisis Support- Children s Emergency Shelter H0004 HO IP Behavioral Health Counseling, Professional, Individual H0004 HO HQ IP Behavioral Health Counseling, Professional, Group H0004 IP Behavioral Health Counseling, Supportive and Individual H0004 HQ IP Behavioral Health Counseling, Supportive, Individual Appendices... i-ix APS Healthcare, Inc.-WV 3

4 WV Clinic, Rehabilitation, and Targeted Case Management Options AND BHHF Services for Bureau for Behavioral Health Services Contract Providers APS West Virginia Medicaid ASO the right consumer in the right service at the right time with the right provider at the right intensity for the right duration with the right outcome These Utilization and Service Guidelines are organized to provide an overview of the Medicaid Clinic, Rehabilitation, and Targeted Case Management Options for providing community behavioral health services, and the specific services that comprise these options. Additionally, these Utilization Management Guidelines contain the Crisis Services provided by Bureau for Behavioral Health and Health Facilities (BHHF) contract providers to individuals eligible to receive BHHF funding for these services. Notice that each service listing provides a definition, service tier, program option, initial authorization limits, increments of reauthorization, and service exclusions. In addition, the service listing provides consumer-specific criteria, which discusses the conditions for admission, continuing stay, discharge, clinical exclusions, and basic documentation requirements. The elements of these service listings will be the basis for utilization reviews and management by APS Healthcare, Inc. (APS). APS has developed the guidelines from the current Clinic Option, Rehabilitation Option, and Targeted Case Management Service Codes, including the assignment of standard codes for each procedure. Admission and continuing stay criteria for these services are developed based upon the intensity of the service in question. Medicaid consumers are served best when services are tailored to individual needs and are provided in the least restrictive setting. Low intensity services utilized for Consumer Intake and Triage require registration and APS Healthcare, Inc.-WV 4

5 are open to all Medicaid consumers with a known or suspected behavioral health disorder. Crisis services provided to BHHF eligible consumers are identified and criteria for requesting these services are specified based on policy from the Bureau for Behavioral Health and Health Facilities. Services requiring completion of the West Virginia APS CareConnection include continued outpatient services after an initial benefit has been exhausted, and high intensity services provided to long-term consumers or consumers with treatment needs that require service intensity or duration beyond the registration level. Prior authorizations are required for these services. To register a service or request an authorization, the service provider submits the appropriate required information to APS. The provider will be notified if the request is approved, if additional information is needed to make the decision (pend), and/or what alternative services may be recommended. In the event the consumer needs service beyond the initial authorized units, the provider will submit another prior authorization request for the service. The provider will want to submit a prior authorization request before all the service has expired. After registration or request for authorization, the decision will be transmitted to the provider to allow continued service provision and billing, or APS will communicate with the provider to resolve the request. Duplication of services by providers is not allowed. It is the responsibility of the provider(s) to coordinate care and to authorize service appropriately. For the consumers served by multiple behavioral health providers, the provider providing the case management services or the lead provider in treatment planning is considered the primary provider by APS. Each provider is responsible for registering or submitting the request for authorization for the services they provide. We are hopeful that this will encourage continued community coordination of services for consumers. The information provided at the Registration tier (Tier 1) is brief and is primarily used to track the utilization of various services as well as diagnostic groups and focus of treatment. Tier 1 also provides the information necessary for the submission of the Mental Health and Substance Abuse Block Grants for BHHF Crisis Service codes. The information submitted at Tier 2 and Tier 3 of the West Virginia APS CareConnection provides a clinically relevant summary of symptomatology and level of functioning but alone is not always sufficient documentation of medical necessity. APS strives to assist the provider in developing an appropriate plan of care for each consumer. Typically, the vast majority of discrepancies between the request for service and the final authorization APS Healthcare, Inc.-WV 5

6 are resolved through discussion and mutual agreement. In the event that a consumer truly does not have a demonstrated behavioral health, or MR/DD, diagnosis and/or a treatment service need that meets the guidelines for care, and an agreement cannot be reached for another service that better meets the need, the request will be denied. In this event, it is the provider s responsibility to share the denial with the consumer and their support system so that alternative arrangements may be made. Information at Tier 2 and Tier 3, along with the Federal Substance Abuse Reporting Data, is utilized for completing required tables for the Federal Mental Health and Substance Abuse Block Grants, as well as linking to the Client Service Data Report (CSDR) and other financial reporting by BHHF Contract Providers. Prior authorization approval does not guarantee payment for services. Prior authorization is an initial determination that medical necessity requirements are met for the requested service. In the Managed Care position paper, published in 1999, the state of West Virginia introduced the following definition of medical necessity: services and supplies that are (1) appropriate and necessary for the symptoms, diagnosis or treatment of an illness; (2) provided for the diagnosis or direct care of an illness; (3) within the standards of good practice; (4) not primarily for the convenience of the plan member or provider; and (5) the most appropriate level of care that can be safely provided. The Clinic and Rehabilitation Services Manual more clearly defines the services and criteria utilized to meet parts (1) and (2) of the definition above. In determining the appropriateness and necessity of services under the Clinic and Rehabilitation Options for the treatment of specific individuals, the diagnosis, level of functioning, clinical symptoms and stability and available support system are evaluated. This is the current role of the ASO: to devise clinical rules and review processes that evaluate these characteristics of individuals and ensure that Clinic, Rehabilitation, and Targeted Case Management services requested are medically necessary. The Utilization Management Guidelines for the WV Rehabilitation and Clinic Options published by APS serve to outline the requirements for diagnosis, level of functional impairment and clinical symptoms of individuals who require the service. Level of available support is evaluated based on treatment history, and the level of assistance required for the consumer to perform activities of daily living. Additionally, the UM guidelines outline standards of good clinical practice. Part (4) of the definition, in the context of the Clinic and Rehabilitation Options, relates to services requested by the consumer that may be helpful but are not APS Healthcare, Inc.-WV 6

7 medically necessary, as well as to alternative and complementary services not addressed in the manuals. This portion of the definition prohibits the utilization of treatment codes to provide service that meets a consumer need but does not meet the medical necessity criteria. Prior authorization review will utilize these guidelines as well as specific clinical requirements for the specific service(s) requested. Part (5) of the definition which refers to the most appropriate level of care that can be safely provided, in the context of service delivery under the Clinic and Rehabilitation Options, relates to the least restrictive service acceptable to meet the consumer s needs while ensuring that the consumer does not represent a direct danger to himself or others in the community. While the information submitted on the West Virginia APS CareConnection is a clinically relevant summary, it alone is not sufficient documentation of medical necessity. For this reason, APS care managers may request additional information to make prior authorization decisions for consumers who do not clearly meet the UM guidelines for the service or do not meet clearly meet medical necessity requirements. The assessment, treatment plan, additional service plans, and documentation of services all serve to document the appropriateness and medical necessity of services provided to a consumer. Retrospective reviews may determine that services as planned and documented do not meet the criteria requirements in the Medicaid manual. Through internal utilization management processes, providers need to ensure that medical necessity documentation is complete and consistent throughout the clinical record. The purpose of the utilization review and management system is to assure that the rights as listed above are in place for each consumer and to assure consistency in level and duration of treatment and support among service providers and throughout regions. APS Healthcare, Inc.-WV 7

8 APS West Virginia Medicaid ASO Definitions Behavioral Health Rehabilitation Services: Includes the medical and remedial services included in the Rehabilitation Option, recommended by a physician or licensed psychologist, for the purpose of reducing physical or mental disability and restoration of a recipient to his/her best functional level. A. All services are subject to a determination of medical/clinical necessity. The following four factors will be included as part of this determination: 1. Diagnosis 2. Level of functioning 3. Evidence of clinical stability 4. Available support system B. Consideration of the above factors in the treatment planning process will be documented and re-evaluated at regular treatment plan reviews. C. When required, diagnostic and standardized instruments to measure functioning which are approved by the Bureau for Medical Services will be administered at the initial evaluation and as necessary to represent the clinical condition of the consumer. D. The results of above measures will be included as part of the clinical record and serve as a part of the required documentation of service needs and justification for the levels and type of services requested and provided. Behavioral Health Clinic Services: Includes preventive, diagnostic, therapeutic or palliative items or services included in the Clinic Option and provided to outpatients under the direction of a physician. These services must be furnished by a facility that is not part of a hospital, but is organized and operated to provide medical care to outpatients. Clinic Services must be provided at the clinic, the only exception being services provided to the homeless. A. Clinic Services are under the direction of a physician: 1. A physician must sign the Authorization for Services Form. 2. The physician must have a face-to-face contact with the consumer before or at the master treatment planning juncture to authorize services. 3. Physician will periodically review the continued need for care. B. All Clinic Services are subject to a determination of medical/clinical necessity. The following four factors will be included as part of this determination: 1. Diagnosis 2. Level of functioning 3. Evidence of clinical stability 4. Available support system C. Consideration of these factors in the treatment planning process will be documented and re-evaluated at regular treatment plan reviews. APS Healthcare, Inc.-WV 8

9 D. When required, diagnostic and standardized instruments to measure functioning which are approved by the Bureau for Medical Services will be administered at the initial evaluation and as necessary to represent the clinical condition of the consumer. E. The results of the above measures will be available as part of the clinical record and serve as a part of the required documentation of service need and justification for the level and type of service requested and provided. Consumer: A. One who is determined Medicaid eligible for Behavioral Health Rehabilitation Services designated for all individuals with conditions associated with mental illness, substance abuse and/or drug dependence. or- B. One who is eligible for the Behavioral Health Clinic Services receiving professional services at an organized medical facility, or distinct part of such a facility, neither of which is providing the consumer with room and board and professional services on a continuous 24 hour-a-day basis. -and/or- C. One who is eligible for Targeted Case Management Services: Children with mental illness Adults with mental illness Children with substance-related disorders Adults with substance-related disorders Children who qualify for early intervention Children with mental retardation/developmental disabilities Adults with mental retardation/developmental disabilities and- D. One who is approved for specific Clinic, Rehabilitation, and/or Targeted Case Management Services based on meeting eligibility for specific service levels. BHHF Eligible Consumer: Consumers eligible for BHHF services must: o Be a West Virginia Resident ando Be at or below 200% of the current Federal Poverty Guidelines ando Meet at least one (1) of the following conditions: Have an eligible DSM diagnosis (under the Medicaid Clinic, Rehabilitation or Targeted Case Management options) -or- Meet the state eligibility requirements for mental retardation/developmental disability -or- Has a history of inpatient hospitalization for a mental health, substance abuse or developmental disability -or- Lives in a 24 hour supervised setting (such as a group home) -or- Receives supportive residential services to assist in management of symptoms or functional impairments related to a mental health condition, substance abuse condition or developmental disability -or- Receives services required by West Virginia Code, Chapter 27-or- Receives a crisis service APS Healthcare, Inc.-WV 9

10 BHHF Contract Provider: These providers have Grant Agreements with the Bureau for Behavioral Health and Health Facilities to provide services required by the West Virginia Code, Chapter 27 and other specific policies promulgated by BHHF to provide behavioral health services through the use of indigent care dollars and other state and discretionary dollars. These providers are required to meet specific data submission and reporting requirements set forth in their Grant Agreement. Providers who only receive Federal Mental Health and/or Substance Abuse Block Grant funds to provide specific targeted services are not BHHF contract providers BUT are required to meet specific data and reporting requirements set forth in their Grant Agreement related to the receipt of Block Grant funds. Service Tier General Criteria: Registration Services (Tier 1): All Medicaid consumers with a known or suspected behavioral health disorder. Brief, low intensity outpatient services are required to treat the identified behavioral health condition, with the purpose of reducing symptoms and/or returning the individual to their previous level of functioning. BHHF Contract Providers complete additional fields for registration to meet Federal Mental Health and Substance Abuse Block Grant requirements. All provider groups complete these data elements but for non-bhhf contract providers the fields are part of the Tier 2 data set. Tier 2 Services: Consumers who meet the following criteria: 1. Consumer requires continued services 1-2 times a week or less. 2. Symptoms are mild to moderate. 3. Consumer manages tasks of community living with moderate to no support. 4. Consumer has a severe and persistent behavioral health disorder requiring low intensity outpatient care. Tier 3 Services: Consumers who meet the following criteria: 1. Consumer requires services 3-5 days per week. 2. Symptoms are moderate to severe. 3. Consumer requires direct assistance to manage tasks of community living. 4. Consumer has a severe and persistent behavioral health disorder (MH or SA) which requires Intensive Services and in which the individual displays a high level of symptoms and a low level of functioning. The required services are often residential in nature and withdrawal of services may result in hospitalization or institutionalization. APS Healthcare, Inc.-WV 10

11 Registration Service Tier 1

12 H2011 CRISIS INTERVENTION Definition: Unscheduled, direct face-to-face intervention with a recipient in need of emergency or psychiatric interventions in order to resolve a crisis related to acute or severe psychiatric signs and symptoms. Depending on the specific type of crisis, an array of treatment modalities is available. These include, but are not limited to, individual intervention and/or family intervention. The goal of crisis intervention is to respond immediately, assess the situation and stabilize as quickly as possible. This service is not intended for use as an emergency response to situation such as a consumer running out of medication or housing problems. Any such activities will be considered inappropriate for billing of this service by the provider. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Registration MH, SA, MR/DD, A & C BHHF Consumers* Clinic/Rehabilitation Registration required for 16 units/ per consumer/per 30 days Unit = 15 minutes 1. Registration required for additional units after 30 days by any provider previously utilizing the benefit for the same consumer. 16 units/per consumer/ per 30 days Unit = 15 minutes 2. Another registration is required for any provider to exceed the limit of sixteen (16) units/ per consumer/per 30 days for utilization review purposes or- if the service is provided to address a new crisis episode. 1. The consumer has a known or suspected behavioral health diagnosis, -and- 2. Treatment at a lower level of care has been attempted or given serious consideration, - and- 3. Psychiatric signs and symptoms are acute or severe, -and- 4. Consumer has insufficient or severely limited resources or skills necessary to cope with the immediate crisis, -and- 5. Consumer exhibits lack of judgment and/or impulse control and/or cognitive/perceptual abilities, -and- 6. Consumer requires an unscheduled face-toface intervention -or- APS Healthcare, Inc.-WV 12 June 15, 2004 Updated January 1, 2006

13 Continuing Stay Criteria Discharge Criteria Service Exclusions Clinical Exclusion 7. The consumer is a risk to self, others and/or property. This service may be utilized at various points in the consumers course of treatment and recovery; however, each intervention is intended to be a discreet time-limited service, which stabilizes the consumer and moves him/her to the appropriate level of care. 1. Crisis situation is resolved and an adequate continuing care plan is established. 2. Consumer no longer meets admissions criteria. Not to be used as an emergency response to a situation such as a consumer running out of medication or housing problems. No other Clinic, Rehabilitation or Targeted Case Management Service may be provided during the period for which Crisis Intervention Services are being billed. The consumer does not require inpatient care due to level of danger to self or others. Documentation must include: A summary of events leading up to the crisis; methods of therapeutic intervention; outcome of the service; specific times and dates of service; place of service; and signature of qualified staff providing the crisis intervention service. A physician/licensed psychologist/physician assistant/nurse practitioner must review all Documentation pertinent documentation within 72 hours of the crisis and document their findings. Documentation must include the date and start/stop times of the review, recommendations for follow-up and whether the current treatment plan can be maintained or should be modified and signature of the physician/licensed psychologist/physician assistant/ nurse practitioner. Additional Service Criteria: 1. * BHHF follows the same utilization management guidelines as Medicaid for data submission and prior authorization of this service BUT sets specific rates with their contract providers which may or may not equal the current Medicaid rate. The actual units utilized and the date(s) of service are submitted on the CSDR and must fall within a registration APS Healthcare, Inc.-WV 13 June 15, 2004 Updated January 1, 2006

14 authorization period. 2. BHHF contract Providers will continue to complete existing reports such as the Involuntary Commitment Report and Residential Substance Abuse Referral forms if required by their Grant Agreement. Services provided to consumers at PI Shelters will continue to be reported by the Prevention Resource Center. Crisis Respite and Respite sites used for adults and children with developmental disabilities will submit a quarterly report on the utilization of respite services, in addition to any other specific crisis services provided. Services provided specifically to persons affected by disasters or critical incidents will be reported by accessing the DHHR web page, and using forms developed to record these types of crisis activities. 3. The mix of services offered to the consumer will be important in determining the appropriateness of this service. The use of crisis intervention will be retrospectively reviewed and the evaluation will include the clinical appropriateness of the service in conjunction with other services offered to and provided to the consumer. For example, if a person presents in crisis and the crisis is alleviated within an hour, ongoing supportive services may then be utilized to support the consumer or targeted case management services may be provided to link and refer to needed services. 4. Physician Assistant may also perform this service. Permissions granted to Physician Assistants can be found in the West Virginia Code [(b) and (o)] and legislative rule 11 CSR 1B. Program Instruction MA issued January 6, 2001 allows the Physician Assistant to be reimbursed for services rendered to Medicaid eligible individuals as outlined in their job description submitted to the West Virginia Board of Medicine. 5. A Nurse Practitioner with a Psychiatric Certification may perform this service. Any other Nurse Practitioner may perform this service provided it is within their scope of practice as defined by their Licensing Board and their contract with the Bureau for Medical Services and under the supervision of a psychiatrist. APS Healthcare, Inc.-WV 14 June 15, 2004 Updated January 1, 2006

15 BH496 CRISIS PHONE CALL Definition: Services provided in response to phone calls made by any individual who perceives he or she is involved in a crisis situation, and requests immediate assistance. Services may include, but are not limited to, assessment, triage, referrals, information and/or crisis resolution. Services may be provided to active consumers, previously active consumers whose cases have been closed, individuals previously unknown to the provider, or any individual, family member, or community resident who perceives he or she is involved in a crisis situation. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Discharge Criteria Service Exclusions Registration MH, SA, MR/DD, A & C BHHF Consumers NONE- BHHF SERVICE ONLY Registration required for 48 units/ per consumer/per 92 (ninety two) days per provider Unit = 10 minutes 1. Registration required for additional units after 92 days by any provider previously utilizing the benefit for the same consumer. 48 units/per consumer/ per 92 days Unit = 10 minutes 2. Another registration is required for any provider to exceed the limit of 48 units/ per consumer/per 92 days for utilization review purposes or- if the service is provided to address a new crisis episode. The consumer perceives he or she is involved in a crisis situation and requests assistance. This service may be utilized at any time; however, crisis calls should be linked to a specific crisis episode and a new registration sought when a new crisis episode is identified for the same consumer. 1. Crisis situation is resolved and an adequate continuing care plan is established. 2. Consumer no longer meets admissions criteria. When crisis calls are part of the resolution to a face-toface crisis intervention, use H2011 Crisis Intervention. APS Healthcare, Inc.-WV 15

16 Clinical Exclusion Documentation None. Documentation must include: a record of the contact, including the nature (content) of the contact, the disposition or outcome and the date and time of the contact. Multiple crisis calls related to the same crisis episode can be recorded in a single note. For consumers with a clinical record with the provider, the note should be placed in the record. For any consumer without a clinical record, or in instances where the caller s identity is unknown, calls may be logged, including an identification number (to replace consumer ID for known or identified consumers). Additional Service Criteria: 1. The actual units utilized and the date(s) of service are submitted on the CSDR and must fall within a registration authorization period. 2. The mix of services offered to the consumer will be important in determining the appropriateness of this service. 3. BHHF contract Providers will continue to complete existing reports such as the Involuntary Commitment Report and Residential Substance Abuse Referral forms if required by their Grant Agreement. Services provided to consumers at PI Shelters will continue to be reported by the Prevention Resource Center. Crisis Respite and Respite sites used for adults and children with developmental disabilities will submit a quarterly report on the utilization of respite services, in addition to any other specific crisis services provided. Services provided specifically to persons affected by disasters or critical incidents will be reported by accessing the DHHR web page, and using forms developed to record these types of crisis activities. APS Healthcare, Inc.-WV 16

17 BH497 INVOLUNTARY COMMITMENT LINKAGE SERVICES Definition: Activities performed that relate to the involuntary commitment process, specifically related to a BHHF Contractor s responsibilities in that process. Activities may include, but are not limited to, assisting a mental hygiene commissioner or circuit clerk in setting up hearings, obtaining information for the evaluator and other parties in the process, participating in the hearing, identifying and securing the most integrated setting for an individual for whom probable cause is found, assisting in the development of a voluntary treatment agreement, or linking an individual in need of services but for whom probable cause is not found to essential and desired services. This service may also include working with or obtaining information from collateral sources, such as family or community members. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Discharge Criteria Registration MH, SA, MR/DD, A & C BHHF Consumers NONE- BHHF SERVICE ONLY Registration required for 48 units/ per consumer/per 92 days per provider Unit = 10 minutes 1. Registration required for additional units after 92 days by any provider previously utilizing the benefit for the same consumer. 48 units/per consumer/ per 92 days Unit = 10 minutes 2. Another registration is required for any provider to exceed the limit of 48 units/ per consumer/per 92 days for utilization review purposes or- if the service is provided to address a new commitment episode. The consumer is involved in an involuntary commitment proceeding. This service may be utilized at any time; however, a new registration should be sought each time an involuntary commitment proceeding is initiated for the same consumer (even within the 30 day registration period). Involuntary commitment has been resolved. APS Healthcare, Inc.-WV 17

18 Service Exclusions Clinical Exclusion Documentation Some face-to-face activities may be appropriately coded under H2011 Crisis Intervention. Face-to-face activities performed by professionals completing certifications should be billed as BH498 Involuntary Commitment Certification Services. None. Documentation must include: a record of the contact, including the nature (content) of the contact, the disposition or outcome and the date and time of the contact. For consumers with a clinical record with the provider, the note should be placed in the record. For consumers not receiving services from the provider, the record of involuntary commitment services should be kept in a secure location to maintain confidentiality. Additional Service Criteria: 1. The actual units utilized and the date(s) of service are submitted on the CSDR and must fall within a registration authorization period. 2. BHHF contract Providers will continue to complete existing reports such as the Involuntary Commitment Report and Residential Substance Abuse Referral forms if required by their Grant Agreement. Services provided to consumers at PI Shelters will continue to be reported by the Prevention Resource Center. Crisis Respite and Respite sites used for adults and children with developmental disabilities will submit a quarterly report on the utilization of respite services, in addition to any other specific crisis services provided. Services provided specifically to persons affected by disasters or critical incidents will be reported by accessing the DHHR web page, and using forms developed to record these types of crisis activities. APS Healthcare, Inc.-WV 18

19 BH498 INVOLUNTARY COMMITMENT CERTIFICATION SERVICES Definition: Activities related exclusively to the certification for the involuntary commitment process. This is work performed only by the following professionals related to the provider s responsibilities in the commitment process: licensed psychologists, psychiatrists or other physicians, licensed independent clinical social workers, or advanced nurse practitioners with psychiatric certification. It includes the professional evaluation and expert testimony during the involuntary commitment hearing. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Discharge Criteria Service Exclusions Clinical Exclusion Registration MH, SA, MR/DD, A & C BHHF Consumers NONE- BHHF SERVICE ONLY Registration required for 16 units/ per consumer/per 30 days per provider Unit = 10 minutes 1. Registration required for additional units after 30 days by any provider previously utilizing the benefit for the same consumer. 16 units/per consumer/ per 30 days Unit = 10 minutes 2. Another registration is required for any provider to exceed the limit of sixteen (16) units/ per consumer/per 30 days for utilization review purposes or- if the service is provided to address a new commitment episode. The consumer is involved in an involuntary commitment proceeding. This service may be utilized at any time; however, a new registration should be sought each time an involuntary commitment proceeding is initiated for the same consumer (even within the 30 day registration period). Involuntary commitment has been resolved. None. None. APS Healthcare, Inc.-WV 19

20 Documentation Documentation must include: a record of the contact, including the nature (content) of the contact, the disposition or outcome and the date and time of the contact. For consumers with a clinical record with the provider, the note should be placed in the record. For consumers not receiving services from the provider, the record of involuntary commitment services should be kept in a secure location to maintain confidentiality. Additional Service Criteria: 1. The actual units utilized and the date(s) of service are submitted on the CSDR and must fall within a registration authorization period. 2. BHHF contract Providers will continue to complete existing reports such as the Involuntary Commitment Report and Residential Substance Abuse Referral forms if required by their Grant Agreement. Services provided to consumers at PI Shelters will continue to be reported by the Prevention Resource Center. Crisis Respite and Respite sites used for adults and children with developmental disabilities will submit a quarterly report on the utilization of respite services, in addition to any other specific crisis services provided. Services provided specifically to persons affected by disasters or critical incidents will be reported by accessing the DHHR web page, and using forms developed to record these types of crisis activities. APS Healthcare, Inc.-WV 20

21 H0031 Mental Health Assessment by a Non-Physician Definition: Initial or reassessment evaluation to determine the needs, strengths, functioning level(s), mental status, and/or social history of an individual. Specialty evaluations necessary to assess needs, strengths or functioning, such as occupational therapy, nutritional, and functional skills assessments, are included. The administration and scoring of functional skills assessments are included. The administration and scoring of functional assessment instruments necessary for the medical necessity determination and level of care needed as part of this service are included. This code may also be used for special requests of West Virginia Department of Health and Human Resources for assessments, reports, and court testimony on adults or children for cases of suspected abuse or neglect. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Registration Mental Health (MH), Substance Abuse (SA), Mental Retardation/Developmental Disability (MR/DD), Adult & Child (A & C) Clinic/Rehabilitation Registration required for 6 events/ per consumer/per year 6 units for one year from date of initial service Unit = Event 1. Registration required for additional units after one year by any provider previously utilizing the benefit for the same consumer. 6 units for one year Unit = Event 2. Tier 2 data submission is required for any provider to exceed the limit of six (6) units per consumer/per year. This level of data is required to exceed the initial authorization limit and demonstrate medical necessity. The need for the additional unit should be described in the free-text field. 1. Consumer has, or is suspected of having, a behavioral health diagnosis, -and- 2. Consumer has just entered the service system, - or- 3. Consumer has need of an assessment due to request of West Virginia Department of Health and Human Resources for assessments, reports, and court testimony on adults or children for cases of suspected abuse or neglect, -or- 4. Assessment is needed to meet state requirements to authorize Medicaid services APS Healthcare, Inc.-WV 21

22 Continuing Stay Criteria Discharge Criteria Service Exclusions Clinical Exclusions Documentation and/or to evaluate the current treatment plan. 1. Consumer has a need of an assessment due to a change in consumer clinical/functional status. 2. Consumer has need of an assessment due to request of West Virginia Department of Health and Human Resources for assessments, reports, and court testimony on adults or children for cases of suspected abuse or neglect. 3. Reassessment is needed to meet state requirements to reauthorize Medicaid services and/or to update/evaluate current treatment plan. Consumer has withdrawn or been discharged from service. None None Documentation shall consist of the completed evaluation, (signed with credential initial(s) by the staff member who provided the service.) The documentation must include the place of evaluation, the date of service, and the actual time spent providing the service. The actual time spent must be documented by listing the start and stop times. Additional Service Criteria: 1. The assessments are evaluative or standardized testing instruments. 2. The assessments are administered by qualified staff and are necessary to make determinations concerning the mental, physical, and functional status of the consumer or as required to determine medical necessity. APS Healthcare, Inc.-WV 22

23 T1023 HE Screening by Licensed Psychologist Definition: Brief psychological evaluation with written report by a licensed psychologist to determine the appropriateness of consideration of an individual for participation/placement in a specified program, project or treatment protocol. This code may be utilized for the purposes of performing a brief psychological for the purposes of rendering or confirming diagnosis, evaluating or completing court ordered psychological procedures, and responding to emergent requests such as consumer evaluation in mental hygiene commitment proceedings. Code should be used when a more in depth assessment is indicated. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Registration MH, SA, MR/DD, A & C Clinic/Rehabilitation Registration required for 1unit/ per 184 days/per consumer 1unit/ per consumer/per 184 days Unit = Event/Session 1. Registration required for additional units after 184 days by any provider previously utilizing the benefit for the same consumer. 1 session/per consumer/ per 184 days Unit= Session/Event 2. Tier 2 data submission is required to exceed limit of one (1) session/per consumer/per 184 days. This level of data is required to exceed initial authorization limit and demonstrate medical necessity. Only one unit (session) can be approved and the need for the additional unit should be described in the free-text field. 1. The consumer has a known or suspected behavioral health diagnosis, -and- 2. The initial screening/intake information indicates a need for additional information, -or- 3. Consumer s situation/functioning has changed in such a way that previous assessments are inadequate, -or- 4. A brief psychological is required for the purposes of rendering/confirming diagnosis, evaluation required by the court, or evaluation in mental hygiene commitment proceedings. None. APS Healthcare, Inc.-WV 23

24 Discharge Criteria Service Exclusions Clinical Exclusions Documentation Each intervention is intended to be a discreet timelimited service, which is utilized to direct the consumer to the appropriate level and type of care or should be used when a more indepth assessment is indicated. None. Documentation shall be a completed evaluation, signed by a licensed psychologist (including evidence of provision of results to appropriate parties). The documentation must include the place of the evaluation, the date, and the actual time spent providing the service. The actual time spent must be documented by listing the start and stop times. Additional Service Criteria: A Licensed Psychologist or a psychologist under supervision for licensure who meets the requirements of the West Virginia Board of Examiners may perform this service. APS Healthcare, Inc.-WV 24

25 96101 Psychological Testing with Interpretation and Report Definition: Evaluation by a psychologist including psychological testing with interpretation and report. Psychological testing includes, but is not limited to: psychodiagnostic assessment of personality, psychopathology, emotionality, and intellectual abilities (e.g., WAIS-R, Rorschach, MMPI). Academic assessment and assessment required to determine the needs, strengths, functioning level(s), mental status and/or social history of an individual are also included. Documentation requires scoring and interpretation of testing and a written report including findings and recommendations. Service Tier Target Population Program Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Registration Mental Health (MH), Substance Abuse (SA), Mental Retardation/Developmental Disability (MR/DD), Adult & Child (A&C) Clinic/Rehabilitation Registration required for 4 hours/per consumer/per year 4 units/per consumer/per year Unit = One hour 1. Registration required for additional units after year by any provider previously utilizing the benefit for the same consumer. 4 units/per consumer/ per year Unit = One hour 2. Tier 2 data submission is required for any provider to exceed the limit of four (4) units per consumer/per year. This level of data is required to exceed the initial authorization limit and demonstrate medical necessity. The need for these additional units should be described in the free-text field. 1. Consumer has, or is suspected of having, a behavioral health diagnosis, -or- 2. Consumer requires psychological testing or evaluation for a specific purpose, -or- 3. Psychological testing/evaluation is required to make specific recommendations regarding additional treatment or services required by the individual. None. APS Healthcare, Inc.-WV 25 June 15, 2004 Updated December 1, 2005

26 Discharge Criteria Service Exclusions Clinical Exclusions Documentation Requirement Each intervention is intended to be a discreet timelimited service, which is utilized to direct the consumer to the appropriate level and type of care should be utilized for developmental testing and evaluation. None Documentation shall be a completed evaluation, including scoring and interpretation of testing and a written report of findings and recommendations (including evidence of provision of results to appropriate parties), signed by a licensed psychologist. The documentation must include the place of the evaluation, the date, and the actual time spent providing the service. The actual time spent must be documented by listing the start and stop times. Additional Service Criteria: 1. Testing is for evaluative purpose(s) and purpose(s) is stated in the report. 2. A Licensed Psychologist or a psychologist under supervision for licensure who meets the requirements of the West Virginia Board of Examiners must complete the testing and report/interpretation. APS Healthcare, Inc.-WV 26 June 15, 2004 Updated December 1, 2005

27 96110 Developmental Testing: Limited Definition: Developmental Testing by a psychologist including limited developmental testing with interpretation and report. Developmental testing includes, but is not limited to: Developmental Screening Test II, Early Language Milestone Screen, and other developmental screening instruments. Documentation requires scoring and interpretation of testing and a written report including findings and recommendations. Note: Extensive and general psychological testing should be provided utilizing Psychological Testing. Service Tier Target Population Program Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Discharge Criteria Registration MH, SA, MR/DD, A&C Clinic/Rehabilitation Registration required for 2 units/per consumer/per 184 days 2 units/per consumer/per 184 days Unit = Event 1. Registration required for additional units after 184 days by any provider previously utilizing the benefit for the same consumer. 2 units/per consumer/per 184 days Unit = Event 2. Tier 2 data submission is required to exceed the limit of two (2) units per consumer/per 184 days. This level of data is required to exceed the initial authorization limit and demonstrate medical necessity. The need for these additional units should be described in the free-text field. 1. Consumer has, or is suspected of having, a developmental delay and/or behavioral health condition, -or- 2. Consumer requires developmental testing or evaluation for a specific purpose, -or- 3. Developmental testing/evaluation is required to make specific recommendations regarding additional treatment or services required by the individual. None. Each intervention is intended to be a discreet time-limited service, which is utilized to direct the consumer to the appropriate level and type of APS Healthcare, Inc.-WV 27 June 15, 2004 Updated December 1, 2005

28 Service Exclusions Clinical Exclusions Documentation Requirement care. Testing that encompasses more extensive assessment than developmental assessment should be performed using Psychological Testing. None Documentation shall be a completed evaluation, including scoring and interpretation of testing and a written report of findings and recommendations (including evidence of provision of results to appropriate parties), signed by a licensed psychologist. The documentation must include the place of the evaluation, the date, and the actual time spent providing the service. The actual time spent must be documented by listing the start and stop times. Additional Service Criteria: 1. Testing is for evaluative purpose(s) and purpose(s) is stated in the report. 2. A Licensed Psychologist or a psychologist under supervision for licensure who meets the requirements of the West Virginia Board of Examiners must complete the testing and report/interpretation. 3. If performed by staff other than a psychologist (e.g. psychometrician), a licensed psychologist must review, sign, and date the completed interpretation and report. APS Healthcare, Inc.-WV 28 June 15, 2004 Updated December 1, 2005

29 90801 Psychiatric Diagnostic Interview Examination Definition: Initial or reassessment evaluation of an individual s functional level (s), mental status, etc., by a psychiatrist or psychologist. Psychiatric Diagnostic Interview Examination includes a history, mental status, and a disposition, and may include communication with family or other sources. Service Tier Target Population Medicaid Option Initial Authorization Re-Authorization Admission Criteria Continuing Stay Criteria Discharge Criteria Service Exclusions Clinical Exclusions Registration MH, SA, MR/DD, A&C Clinic & Rehabilitation Registration required for 2 sessions/per consumer/per year Unit = Session/Event 1. Registration required for additional units after one year by any provider previously utilizing the benefit for the same consumer. 2 sessions/per consumer/ per year Unit= Session/Event 2. Tier 2 data submission is required to exceed limit of two (2) sessions/per consumer/per year. This level of data is required to exceed initial authorization limit and demonstrate medical necessity. Only one unit (session) can be approved and the need for the additional unit should be described in the free-text field. 1. Consumer has a known or suspected behavioral health diagnosis, -and- 2. Consumer is entering or reentering the service system, -or- 3. Consumer has need of an assessment due to a change in clinical/functional status. 1. Consumer has a need for further assessment due to findings of initial evaluation and/or changes in functional status or- 2. Reassessment is needed to update/evaluate the current treatment plan. 1. Consumer has withdrawn or been discharged from service. 2. Goals of consumer s Individualized Treatment Plan have been substantially met may not be provided on the same day. None APS Healthcare, Inc.-WV 29 June 15, 2004 Updated December 1, 2005