KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. Non-PIHP Alcohol and Substance Abuse Community Based Services

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1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Non-PIHP Alcohol and Substance Abuse Community Based Services

2 Introduction Section Appendix Forms PART II BILLING INSTRUCTIONS Alcohol and Substance Abuse Community Based Services Billing Instructions... Submission of Claims... Specific Billing Instructions... BENEFITS AND LIMITATIONS Co-Payment... Medical Assessment... Benefit Plan... Medicaid... Procedure Codes and Nomenclature... CMS-1500 UB A-1

3 PART II Issued 7/07 This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to providers of alcohol and substance abuse community based services. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendices. Part I of the provider manual consists of five parts: General Information, General Benefits, General Billing, General Special Requirements, and General Third Party Liability (TPL). Part I contains information that applies to all providers, including Non-Prepaid Inpatient Health Plan (Non-PIHP) alcohol and substance abuse community based services providers. The Billing Instructions subsection gives instructions for completing and submitting the billing form alcohol and substance abuse community based services providers must use when the beneficiary is not assigned to the Pre-paid Inpatient Health Plan (PIHP). If the beneficiary is assigned to the PIHP, contact ValueOptions at The Benefits and Limitations subsection defines specific aspects of the scope of alcohol and substance abuse community based services that are reimbursed by the Kansas Medical Assistance Program (KMAP). The Appendix subsection contains information concerning procedure codes. These appendices were developed to make finding and using procedure codes easier for the biller. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A to , inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations.

4 COMMUNITY BASED SERVICES BILLING INSTRUCTIONS Issued 7/07 Introduction to the CMS-1500 and UB-04 Claim Forms Alcohol and substance abuse community based services providers must use the CMS-1500 or UB-04 claim forms (unless submitting electronically) when requesting payment for medical services provided under KMAP. Examples of the CMS-1500 and UB-04 claim forms are in the Forms section at the end of this manual. The interchange Medicaid Management Information System (MMIS) uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment. EDS does not furnish the CMS-1500 or UB-04 claim forms to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Complete, line-by-line instructions for completion of the UB-04 are available in the Hospital Provider Manual. Submission of Claim: Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, KS BILLING INSTRUCTIONS 7-1

5 7010. Issued 7/07 COMMUNITY BASED SERVICES SPECIFIC BILLING INSTRUCTIONS Unit Billing The appendix provides procedure code and time definitions for billing specific procedures (for example, 30 minutes, 1 hour). When billing according to this definition, bill one unit in field 24G. When billing for less than the amount of time indicated in the definition (less than one unit), bill as follows: ".25" represents one-quarter of the time specified. ".50" represents one-half of the time specified. ".75" represents three-fourths of the time specified. When billing for more than the amount of time indicated in the definition (more than one unit), bill as follows: "1.25" represents one and one-quarter units of the time specified. "1.50" represents one and one-half units of the time specified. "1.75" represents one and three-quarters units of the time specified. "2.00" represents two units of the time specified, and so forth. BILLING INSTRUCTIONS 7-2

6 BENEFITS AND LIMITATIONS CO-PAYMENT Issued 7/07 Alcohol and substance abuse community based services are exempt from co-payment requirements. BENEFITS AND LIMITATIONS 8-1

7 BENEFITS AND LIMITATIONS MEDICAL ASSESSMENT Issued 7/07 The purpose of alcohol and drug assessment and referral is to determine the beneficiary s substance abuse treatment needs. If indicated, this may include the appropriate clinical placement for treatment or other referrals using the Kansas Client Placement Criteria (KCPC). The assessment and subsequent documentation must include factors pertaining to the beneficiary s emotional and physical health, social/family background, legal history, employment history, substance use/abuse, and prior treatments regarding any of the reported conditions. The KCPC may be administered only by approved center staff that has completed training on this placement/assessment instrument as evidenced by training certificates. Approved center staff is defined as clinical program staff members rendering Medicaid-reimbursable services who are credentialed according to the State of Kansas, Addiction and Prevention Services Licensing Standards. To provide Medicaid funded rehabilitation substance abuse treatment services, those services must be recommended by either a physician or other licensed practitioner of the healing arts as medically necessary to restore a beneficiary to his or her best possible functional level. A licensed mental health practitioner (LMHP) is an individual who is licensed in the State of Kansas to diagnose and treat mental illness or substance abuse acting within the scope of all applicable state laws and his or her professional licensure. An LMHP includes individuals licensed to practice independently such as: Licensed psychologist Licensed clinical marriage and family therapist Licensed clinical professional counselor Licensed specialist clinical social worker Licensed clinical psychotherapist An LMHP also includes individuals licensed to practice under supervision or direction: Licensed masters marriage and family therapist Licensed masters professional counselor Licensed masters social worker Licensed masters level psychologist Supervision or direction must be provided by a person who is eligible to provide Medicaid services and is licensed at the clinical level or is a physician. Another form of an other licensed practitioner is an advanced registered nurse practitioner (ARNP). An ARNP may be an eligible LMHP and can provide all services available to an LMHP that are within the ARNP s scope of practice. BENEFITS AND LIMITATIONS 8-2

8 BENEFITS AND LIMITATIONS BENEFIT PLAN Issued 7/07 KMAP beneficiaries are assigned to one or more KMAP benefit plans. The assigned plan or plans are listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, contact the KMAP Customer Service Center at or For example, alcohol and substance abuse community based services are not covered for MediKan beneficiaries under KMAP. If the beneficiary is assigned to the PIHP, all alcohol and substance abuse services are the responsibility of the PIHP. For more information, contact ValueOptions at If the beneficiary resides in a psychiatric residential treatment facility (PRTF), all alcohol and drug abuse services are the responsibility of the PRTF. If the beneficiary is Title XXI, contact Cenpatico Behavioral Health at BENEFITS AND LIMITATIONS 8-3

9 BENEFITS AND LIMITATIONS MEDICAID Issued 7/07 Enrolled KMAP alcohol and substance abuse providers must be licensed by Social and Rehabilitation Services Addiction and Prevention Services (AAPS). Potential KMAP providers must complete the following steps, which will be verified in writing by AAPS prior to the enrollment application with EDS, the fiscal agent: Complete a computer questionnaire provided by AAPS to ensure there is sufficient hardware, software, and Internet access to meet the electronic data collection and reporting requirements Enter into a contract that will provide ongoing KCPC software computer support Receive authorization from AAPS to download and install the KCPC system Provide evidence that clinical staff have attended an AAPS approved KCPC training After completion of the above steps, AAPS will issue a letter of approval and the potential provider will complete an enrollment application with EDS. Upon completion of the enrollment application with EDS, the potential provider will contact AAPS to ensure the process for electronic data collection has occurred. Only services described herein, approved by the Regional Alcohol and Drug Assessment Center (RADAC) and provided by approved center staff in the manner described and in accordance with the beneficiary s individualized treatment plan, are reimbursable by KMAP for alcohol and substance abuse community based services. General Charting Documentation Guidelines All clinical activity delivered in the course of treatment must be outlined in the individualized treatment plan with specific goals based on the assessment of medical necessity for treatment. This treatment plan is reviewed and updated regularly according to guidelines based on the beneficiary s assigned level of care. Documentation must show progress, be legible, and include, at a minimum, the following: Start and stop time Type of clinical activity Major issues covered from the treatment plan goals Complete date to include month, day, and year Staff providing the service and staff signature including credentials Progress notes related to the treatment plan goals BENEFITS AND LIMITATIONS 8-4

10 8400. MEDICAID Issued 7/07 Outpatient Outpatient counseling (behavioral health counseling and therapy or group counseling by a clinician) provides nonresidential alcohol and substance abuse treatment in an individual and/or group setting. Group outpatient counseling consists of counseling delivered in a group setting to two or more beneficiaries. Treatment must be based on an individualized treatment plan which is based on the assessment. This initial treatment plan must be completed within 30 days of the beneficiary s admittance into treatment and must be updated every 90 days. The provider must document every session. Outpatient services are limited to nine hours of scheduled counseling services each seven-day period. Case Management Case management means a one-on-one goal directed service for the substance abuse/dependent beneficiary through which the beneficiary is assisted in obtaining access to needed family, legal, medical, employment, educational, psychiatric, and other services. This service must be part of the treatment plan developed and approved by the RADAC. Case management services must be delivered by the program based upon the results of the KCPC. The worker providing the service must at a minimum have: A high school degree with documented training in federal confidentiality guidelines as they relate to substance abuse At least two years experience working with substance abuse programs Supervision by an AAPS credentialed substance abuse counselor Intensive Outpatient Intensive outpatient treatment (intensive outpatient) means treatment activities based on the individualized treatment plan where services are offered in regularly scheduled sessions throughout the week by approved center staff. Beneficiaries participate in structured therapeutic activities that may include alcohol and/or other substance abuse educational didactic groups, group counseling, and individual counseling. Intensive outpatient treatment consists of participating in services for a minimum of 10 hours (for adults) and six hours (for those under 18) each seven-day period. These minimum requirements must be met to be reimbursed for this level of service. The national standard for adults is for a treatment program to operate at least three hours/day and at least three days/week (for those under 18, at least two hours/day and at least three days/week) and be based on an individualized treatment plan including assessment, counseling, crisis intervention, and activity therapies or education. In Kansas it is only acceptable to bill this code daily if the beneficiary participates in a minimum of 10 hours (or six hours if under 18 years of age) of service in a sevenday period. BENEFITS AND LIMITATIONS 8-5

11 APPENDIX PROCEDURE CODES AND NOMENCLATURE Issued 07/07 The following procedure codes represent an all inclusive list of alcohol and substance abuse community based services billable to KMAP for beneficiaries not assigned to the PIHP. Procedures not listed here are considered noncovered. PROCEDURE Billing Code CPT Nomenclature Substance Abuse Treatment Service Billing Increments H0004 H0005 H0006 H0015 Behavioral Health Counseling & Therapy, per 15 minutes Alcohol and/or drug services; Group counseling by a clinician Alcohol and/or drug services; case management Alcohol and/or drug services; Intensive Outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention and activity therapies or education Outpatient Individual One unit = 15 minutes Outpatient Group Case Management Intensive Outpatient H0001 Alcohol and/or drug assessment Assessment and Referral (KCPC Screening Instrument) APPENDIX A-1

12 FORMS CMS-1500 UB-04

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