Kansas Medical Assistance Program Vertical Perspective KANSAS MEDICAL ASSISTANCE PROVIDER MANUAL PROGRAM Alcohol and Drug Abuse Community Based Services
PART II ALCOHOL & DRUG ABUSE COMMUNITY-BASED SERVICES PROVIDER MANUAL Introduction Section BILLING INSTRUCTIONS Page 7000 Alcohol & Drug Abuse Community-Based Services Billing Instructions... 7-1 Submission of Claim............... 7-1 BENEFITS AND LIMITATIONS 8100 Copayment..................... 8-1 8300 Benefit Plans.................... 8-2 8400 Medicaid..................... 8-3 Appendix I Procedure Codes and Nomenclature............... Forms HCFA 1500
PART II ALCOHOL & DRUG ABUSE COMMUNITY-BASED SERVICES PROVIDER MANUAL 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 Drug Abuse Community-Based services. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendices. The Billing Instructions subsection gives an example of the billing forms applicable to alcohol and drug abuse community-based services. These forms are followed by specific instructions on how to complete and submit claims for payment. The Benefits and Limitations subsection defines specific aspects of the scope of alcohol and drug abuse community-based services that are reimbursed by the Kansas Medical Assistance Program. 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 participant in the Kansas Medical Assistance program, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of 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. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A. 21-3853 and amendments thereto. 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 employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations Page ii
7000. ALCOHOL & DRUG ABUSE COMMUNITY-BASED SERVICES BILLING INSTRUCTIONS Updated 11/03 Introduction to the HCFA-1500 Claim Form Alcohol & Drug Abuse Community-Based Services providers must use the HCFA-1500 claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. An example of the HCFA-1500 claim form is in the forms section at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the HCFA-1500 claim form to providers. Refer to Section 1100. Complete, line by line instructions for completion of the HCFA 1500 is available in the General Billing manual, pages 5-14 through 5-19. 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, Kansas 66601-3571 Page 7-1
8100. COPAYMENT Updated 11/03 BENEFITS AND LIMITATIONS Alcohol and drug abuse community-based services are exempt from copayment requirements. Page 8-1
8300. Benefit Plan Updated 11/03 BENEFITS AND LIMITATIONS Kansas Medical Assistance beneficiaries will be assigned to one or more Medical Assistance benefit plans. The assigned plan or plans will be listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. From the provider's perspective, these benefit plans are very similar to the type of coverage assignment in the previous MMIS. If there are questions about service coverage for a given benefit plan, contact the Medical Assistance Customer Service Center at 1-800-933-6593 or (785) 274-5990 For example, Alcohol and drug abuse community-based services are not covered for MediKan beneficiaries under the Kansas Medical Assistance Program. Page 8-2
BENEFITS AND LIMITATIONS 8400. MEDICAID Updated 10/04 Kansas Medical Assistance Alcohol and Drug Abuse providers must be licensed by Social and Rehabilitation Services Addiction and Prevention Services (AAPS). Potential Medicaid providers shall 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 computer support Receive authorization from AAPS to download and install the Kansas Client Placement Criteria (KCPC) system Clinical staff will attend 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. EDS will: Create a file for all alcohol and drug billing transactions entered for the month and will be submitted via Citrix to AAPS by the 10 th day of the following month Print a summary from the treatment billing system which will be faxed by the 10 th day of the following month to AAPS for quality assurance purposes Upon completion of the enrollment application with EDS the potential provider will contact AAPS to ensure the process for electronic data collection has occurred. Page 8-3
8400. ASSESSMENT Updated 10/04 BENEFITS AND LIMITATIONS The assessment is to determine the client s substance treatment needs and,if indicated, the appropriate clinical placement for treatment using the Kansas Client Placement Criteria (KCPC). Assessment documentation must: Clearly identify the questions and issues to be addressed Describe the individual at the time of the assessment Illustrate the need for initiating or continuing intervention Include the interpretation of findings with impressions and observations Give suggestions and recommendations The client s record must include the following components: A. Referral Source of referral Reason for referral B. Pertinent past and present history C. Treatment Plan Comprehensive and individualized description of the treatment techniques to be used The Addiction Severity Index (ASI) is utilized as a treatment planning tool in conjunction with information received from the KCPC except for social detox and adolescent clients. D. Evaluation Interpretation of completed KCPC/ASI, procedures and techniques used with conclusions reached Recommendations that are related to meaningful aspects of the individual s everyday existence The KCPC and ASI may be administered only by approved center staff that have completed training on both placement/assessment instruments. It is recommended that if an underlying cause of the individual s substance treatment needs is related to a physical cause, a medical examination should precede an evaluation. Results of the medical examination must also be documented in the record. Page 8-4
BENEFITS AND LIMITATIONS 8400. MEDICAID Updated 10/04 Only services described herein, provided by individuals listed, and provided in the manner described are reimbursable by Kansas Medicaid for. Approved Center Staff: Approved center staff is defined as clinical program staff members rendering Medicaidreimbursable services who are credentialed according to the State of Kansas, Addiction and Prevention Services Licensing Standards. Individual Outpatient Counseling: One-to-one counseling by approved center staff conducted under an individual treatment plan based on the findings of the KCPC and ASI and approved by SRS Addiction and Prevention Services or its designee. Individual outpatient therapy is limited to 32 hours per calendar year for consumers not participating in the KAN Be Healthy Program. Forty hours per calendar year are allowed for Kan Be Healthy participants. Group Counseling: Counseling delivered in a group setting to two or more unrelated clients. This service must be conducted by approved center staff and approved by Addiction and Prevention Services or its designee. Group counseling is limited to a maximum of nine hours per week per client for client s age 18 and over. For client s ages 12 to 18 group counseling is limited to a maximum of six hours per week per client.. Individual and group counseling are covered when there is a treatment plan containing goals of treatment. The provider is to document, in legible writing, the amount of time spent in therapy and the major issues covered and changed in the treatment plan or course of treatment. The provider must document that a review of the treatment plan has been conducted every three months. Case Management: Target Group; This service will be reimbursed when provided to the following: Individuals who have had a minimum of three treatment admissions into intermediate or social detox in a twelve month period; Women, predominantly pregnant women and women with children; Individuals who are homeless; Individuals with a co-occurring disorder which means that mental health and substance abuse disorders exist in an individual at the same time; and Individuals who are IV drug users. Page 8-5
8400 Updated 10/04 Case Management cont. Alcohol and Drug Case Management Services are designed to provide assistance to individuals to become more-self-sufficient through delivery of services such as assessment, planning, linkage, advocacy, coordination, monitoring, supportive counseling, and crisis intervention. In addition, a majority of these contacts must occur in usual and customary community locations where the person lives, works, or socializes. All interventions provided shall be related to specific goals set forth in the client s treatment plan. Documentation in progress notes is required to support case management intervention. Case management interventions include the following: Assistance in improving symptom self-management which shall have as its goal the identification and minimization of the negative effects of alcohol and/or other drugs which interfere with an individual s daily living, financial management, academic progress, personal development, family and/or interpersonal relationships and community integration. This may include counseling the individual to recognize alternative solutions and decision making for self-management. Participation in a strengths assessment and planning process with the individual including identifying strengths, resources, and natural supports. The family or other collaterals may also be involved. Also included would be assistance in defining goals based on the assessment and tracking and monitoring individual progress in meeting the goals identified in the treatment plan. Collateral contacts which include phone and written correspondence, as well as face-toface contacts with other social service agencies, schools, housing and employment resources and medical services. Access to supports includes assisting individuals in obtaining access to needed medical, social, educational, and other services. In addition, the service would assist with applications for benefits and arrange transportation to needed services. Case conferences include a scheduled face-to-face meeting between two or more individuals to discuss problems associated with the client s treatment. The conference may include treatment staff, collateral contact, or the client s other agency representatives, not including court appearances or testimony. Each person providing case management shall, at a minimum: Have at least a BA or BS degree or be equivalently qualified by work experience or a combination of work experience in the human services field and education, with one year of experience substituting for one year of education; Possess demonstrated interpersonal skills, ability to work with persons with alcohol and other drug disturbances, and the ability to react effectively in a wide variety of human service situations; Meet the specifications outlined in AAPS policy regarding any ongoing requirements (as in completion of training requirements according to a curriculum approved by the Division of Health Care Policy/Addiction and Prevention Services). Page 8-6
8400 Updated 10/04 Intensive Outpatient Treatment: Alcohol and/or Other Drug Intensive Outpatient and Day Treatment means treatment activities based on the individual treatment plan where services are offered in regularly scheduled sessions throughout the week by approved center staff. Clients participate in structured therapeutic activities that may include alcohol and/or other drug abuse educational didactic/groups, group counseling, and individual counseling. Intensive outpatient treatment programs shall provide at least 3 hours per day and at least 3 days per week individual or group counseling for client s age 18 and over. For client s ages 12 to 18 programs shall provide at least 2 hours/day and at least 3 days per week individual or group counseling Intermediate Treatment: Intermediate Treatment for Alcohol and/or Other Drug Treatment means a residential treatment program which shall have staff on duty, on the premises, 24 hours a day. Approved center staff provide treatment activities based on an individualized treatment plan. Services are offered in regularly scheduled sessions throughout the week. Clients participate in structured activities that include individual counseling, educational didactic/groups, group counseling, community participation, life skills, recreational, and self-help support meetings. Intermediate treatment programs shall provide a minimum of 40 hours of scheduled activities per week. At least 10 hours shall consist of individual, or group counseling. Intermediate treatment programs shall provide treatment services to individuals over age 18, include women with children, and youth between the ages of 12 and 18. Some programs will be co-ed while others will be limited to the treatment of women, some of whom will be accompanied to the program by their children. Page 8-7
8400 Updated 3/05 Reintegration Treatment: Reintegration Treatment for Alcohol and/or Other Drug Treatment means a residential treatment program which shall have staff on duty, on the premises, 24 hours a day. Treatment is designed to support the client s recovery and assist them in re-entering the community. Approved center staff provide treatment activities based on an individualized treatment plan. Reintegration treatment may include therapeutic community programs. Clients participate in structured activities that include individual counseling, educational didactic/groups, group counseling, community participation, life skills, socialization activities, job seeking and job placement skills training, vocational counseling, recreational services, and self-help support meetings. Reintegration treatment programs shall provide a minimum of five hours of individual or group counseling. and no less than ten hours of regularly scheduled treatment services (such as life skills, recreational, and self-help support meetings) through a seven day period. Reintegration therapeutic community programs shall provide treatment for a period of at least six months and not more than two years. Clients are provided at least twenty hours per week of scheduled structured activities that include at least five hours of individual or group counseling. Page 8-8
APPENDIX I PROCEDURE CODES AND NOMENCLATURE Updated 10/04 The following procedure codes represent an all inclusive list of Alcohol and Drug Abuse Community-Based services procedure codes billable to the Kansas Medical Assistance Program. Procedures not listed here are considered non-covered. PROCEDURE CODE NOMENCLATURE H0004 Behavioral Health Counseling and Therapy, per 15 minutes H0005 Group Counseling by a Clinician (one unit = one hour) H0006 Case Management (one unit = one hour) H0015 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 (one unit = one day) H0018 Behavioral Health Short-term Residential (Non-hospital Residential Treatment Program) without room and board, per diem Intermediate Treatment H2012 Reintegration Counseling (one unit = one hour) 99456 Kansas Client Placement Service Assessment and the Addiction Severity Index Use modifier 52 when only one of these tools has been used, either the Kansas Client Placement Service Assessment or the Addiction Severity Index. s Page A1-1
FORMS SECTION HCFA 1500