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Recipient Eligibility for Behavioral Health Overlay Services
, continuedEligibility Criteria The recipient must meet both diagnostic eligibility criteria described in Section A and one of the eight risk factors in Section B.
Section A: Diagnostic Criteria
1. Have an ICD-9-CM diagnosis of 294.8, 294.9, 295.0 through 298.9; 300 through 301.9, 307.1, 307.23, 307.5 through 307.7, 308.0 through 312.4, 312.81 through 314.9; and 303.0 through 305.9; and
2. The child or adolescent demonstrates significant impairment of age-appropriate, developmental progression and psychosocial functioning as a result of the ICD-9-CM diagnosis, in one or more of the following areas:
family, social and peer relationships, educational or vocational.
Section B: Risk Factors
The recipient must be at risk due to one of the following factors and such risk is documented and detailed on the certification form:
1. Within the past 12 months, recipient has exhibited A history of suicidal gestures or, suicide attempts, or self-injurious behavior, or current ideation related to suicidal or self-injurious behavior, though and not be currently in need of acute care;
2. Within the past 12 months, recipient has exhibited A history of physical aggression or violent behavior toward people, animals, or property. This risk may also be evidenced by current threats of such aggression;
3. Within the past 12 months, recipient has A history of running away from home or placements or current verbal threateneds to run away on one or more occasions;
4. Within the past 12 months, recipient has received multiple placements;
5. Recipient hHas recently been removed from home because of abuse or neglect and placed in a group shelter setting;
6. Recipient has aA history, or recent occurrences, of sexual aggression; or 6.7. Recipient has a history of victimizationtrauma;
7.8. Within the past 12 months, recipient has exhibited A history of criminal or delinquent behavior;
8.9. Within the past 12 months, recipient has exhibitedA history of or current psychoactive chemical usesubstance abuse; or
9. A history of disrupted out of home placements; or
10. Recipient has been discharged from a higher level of care and is in need of post stabilization services.
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Recipient Eligibility for Behavioral Health Overlay Services,
continuedRecipient Certification for Services
A Certification of Eligibility for Behavioral Health Overlay Services – Child Welfare form verifying eligibility for behavioral health overlay services in child welfare settings must be completed and signed by a licensed practitioner within 72 hours of provision of services and prior to billing for such services.
Documentation must be present in the recipient clinical record to support the certification.
Note: See Appendix M in this chapter for a copy of the Certification of Eligibility for Behavioral Health Overlay Services – Child Welfare form.
Recipient
Re-Certification for Services
Every six months, a licensed practitioner must complete and sign a new Certification of Eligibility for Behavioral Health Overlay Services – Child
Welfare form verifying the recipient’s continued eligibility. Documentation must be present in the recipient’s clinical record to support the recertification.
Service Requirements
RequiredComponents Behavioral health overlay services in child welfare settings must include the following components:
• An initial screening by a counselor or licensed clinician within 72 hours of provision of services to determine that the recipient meets the criteria for behavioral health overlay services in child welfare settings. If a counselor completes the screening, a licensed clinician must also sign the
Certification of Eligibility for Behavioral Health Overlay Services – Child Welfare.
• An face to face interview by a licensed clinician as part of the treatment planning process.
• Assignment of a counselor, documented in the recipient’s record, to serve as a recipient’s primary counselor who will complete a psychosocial assessment and perform job responsibilities as listed in this section.
• Treatment team meeting within 30 days of admission to develop the individualized treatment plan, in conjunction with the child’s permanency plan.
• Treatment team meetings that include input from the recipient’s family, case worker, psychiatrist, licensed practitioners, counselors, direct care staff, direct care supervisors, any involved case managers, behavior analyst, ancillary services and school personnel, and if applicable Department of Juvenile Justice juvenile probation officers, Child Welfare and Community Based Care organization.
• The psychiatrist’s or licensed practitioner’s review and signature, with certification that services are medically necessary for the recipient, on the treatment plan.
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Service Requirements,
continuedRequired Components, continued
• Provision of individualized treatment interventions for each youth as authorized in the treatment plan.
• A treatment plan review at least every six months, in accordance with Medicaid policy contained in Chapter 2, Section 1.
• Recipient review and re-certification, if indicated, for behavioral health overlay services – child welfare.
• Evaluation and submission of behavioral health outcomes to the Department of Children and Families using the Children’s Functional Assessment Rating Scale.
Focus and
Intensity of Behavioral Health Overlay Services
The focus of the services reimbursed under behavioral health overlay services in child welfare settings must be directly related to the recipient’s behavioral health or substance abuse condition.
The child’s specific needs as identified in the individualized treatment plan shall determine the intensity and individual utilization of treatment services available under behavioral health overlay.
Medical RecordClinical Record and Documentation Requirements
Medical
RecordClinical Record
Requirements
The following components must be documented in the recipient’s medical recordclinical record:
• The name of the primary counselor who coordinates implementation of the recipient’s behavioral health treatment plan.
• The recipient’s initial Certification of Eligibility for Behavioral Health Overlay Services – Child Welfare form(s), and a new Certification of Eligibility each six months the recipient remains eligible for Behavioral Health Overlay Services – Child Welfare. A licensed practitioner must sign each eligibility form.
• A signed copy of the psychosocial assessment and evaluation of the recipient’s behavioral health symptoms, risks, and functional status that was completed and signed by a licensed practitioner prior to the development of the treatment plan.
• An face to face interview by a licensed practitioner completed prior to completion and signing of the individualized treatment plan.
• An individualized treatment plan that meets the criteria for treatment plans as specified in Chapter 2, Section 1 of this handbook and the additional treatment plan requirements that are listed below.
• A behavioral health aftercare plan for any child receiving behavioral health overlay services – child welfare when moved or placed in another setting.
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Medical RecordClinical Record and Documentation Requirements, continued
Medical
RecordClinical Record
Requirements, continued
• A detailed discharge and aftercare plan with specified criteria.
• Treatment plan reviews to determine the effectiveness of the current plan or the need for revision if the child is not making progress., Reviews should be conducted at least every six months, and documented according to Medicaid policy as specified in Chapter 2, Section 1 of this handbook.
• Written substantiationDocumentation in the clinical record that a
behavioral health overlay service – child welfare intervention, as detailed and authorized on the treatment plan, was provided to the child on each day this service was billed, including the name of the staff person providing the service.
• Daily or Wweekly progress notes as described on the following page.
Additional
Individualized Treatment Plan Requirements
The recipient’s individualized treatment plan must be completed and signed by a treating practitioner within 30-days of initiation of behavioral health overlay services. The individualized treatment plan must specify the therapeutic therapy or therapeutic support activities services that will be provided under the behavioral health overlay services – child welfare code, including the amount, frequency, and duration and amount of timed activities.
Examples: If a recipient will receive individual or group therapy, the plan should specify the number of sessions each week, and the length of time that the recipient will need the session(s). If a goal is relationship building through consistent informal contacts with staff throughout each day, this daily
intervention should be specified in the plan.
If the individualized treatment plan contains a behavior management
component, the behavioral analyst must review and sign the component. The behavior management plan must be consistent with treatment outcomes and objectives.
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Documentation Requirements for Weekly Progress Notes
The primary counselor must complete and sign the behavioral health overlay services – child welfare weekly progress notes. The notes must include the following information:
1. Summary of the treatment interventions delivered, the recipient’s response to the interventions and progress toward reaching individualized goals.
2. Information that the interventions authorized in the treatment plan were delivered in accordance with the plan.treatment
3. Summary of the treatment team meetings related to the recipient and information to reflect that the recipient’s individualized goals, progress, and identified treatment needs were discussed.
4. Review of the documentation that substantiates the daily
intervention(s) billed to this service to determine that behavioral health overlay services – child welfare were delivered each day that these services are billed and that the therapeutic interventions and interactions of the primary counselor or the direct care staff are being provided to the recipient based on the recipient’s treatment plan.
Summary of significant events occurring with the child during the week, and information on contacts and visits with family and other agencies.
Clinical Record and Documentation Requirements,
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Documentation
Requirements for Progress Notes
Upon enrollment as a BHOS provider, and once per state fiscal year, providers may choose to document services in either daily progress notes or weekly progress notes. The provider’s choice of service documentation frequency must be clearly identified in the provider’s policy.
Documentation
Requirements for Weekly Progress Notes
For each recipient, the primary counselor must complete and sign behavioral health overlay services weekly progress notes. For each day that BHOS is billed, the weekly progress notes must include the following information:
1. Documentation of the behavioral health overlay services delivered, the recipient’s corresponding responses to the services, and the
recipient’s progress toward reaching individualized goals.
2. Documentation that the services authorized in the treatment plan were delivered in accordance with the plan.
3. Documentation of the treatment team meetings related to the recipient. Include information to reflect that the recipient’s
individualized goals, progress, and treatment needs were discussed.
4. Documentation of significant events, and contacts and visits with family and other agencies.
5. Documentation of any services provided on Saturday or Sunday to substantiate that services were provided on a weekend day.
Documentation
Requirements for Daily Progress Notes
For each recipient, the primary counselor must complete and sign
behavioral health overlay services daily progress notes. For each day that BHOS is billed, the daily progress notes must include the following
information:
1. Documentation of the behavioral health overlay services that were delivered, the recipient’s corresponding responses to the services, and the recipient’s progress toward reaching individualized goals.
2. Documentation that the services authorized in the treatment plan were delivered in accordance with the plan.
3. Documentation of treatment team meetings related to the recipient.
Include information to reflect that the recipient’s individualized goals, progress, and treatment needs were discussed.
4. Documentation of any significant events, and documentation of contacts and visits with family and other agencies.
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Medical RecordClinical Record and Documentation Requirements, continued
Documentation of Family
Involvement
The clinical record must document that the family members were involved in the behavioral health treatment plan development and treatment interventions and must include the goals and objectives for family counseling, or justification if family is not involved.
Weekend
Documentation Direct care staff may document interventions or counselors may gather information on the recipient’s activities, adjustment, mood, and response to staff interventions and interactions to include in the progress notes summary to substantiate that the services were provided on each weekend day.
Documentation of Services Billed Fee-For-Service
Allowable service provided on a fee-for-service basis must be documented in accordance with Medicaid policy.
Documentation of Case
Coordination
Documentation must reflect coordination and linkages with family, the child’s school, primary medical care providers, community services, child welfare caseworker, and if indicated, Department of Juvenile Justice probation officers in accordance with the recipient’s treatment and permanency plan.
Recipient Absences from the Behavioral Health Overlay Services Provider
Recipient
Absences Medicaid reimbursement is not available for the days a recipient is away from the residential provider agency, except for approved therapeutic visits. , hospitalizations, or other crisis placements.
Therapeutic Visits Therapeutic visits are visits the recipient spends with his or her biological, adoptive or extended family or in a potential residential placement setting.
Therapeutic visits must be planned in accordance with the recipient’s permanency plan and authorized in the behavioral health overlay services – child welfare treatment plan. The visitation schedule must be individualized to the specific needs of the child or adolescent. Visitation must not be
dependent on the provider’s holiday and leave schedule for staff.
The recipient’s behavioral health overlay services – child welfare provider must be accessible and must maintain a level of communication during such visits as determined by the counselor and his or her clinical supervisor.
Documentation in the child’s clinical record must substantiate the contact and on-going communication with the child or adolescent during the placement.
Documentation of phone conversations between the provider and recipient constitutes substantiation of on-going communication. Voicemail or email messages are not reimbursable modes of contact.