There has been relevant consumer and family progress toward crisis resolution and progress

Initial Registration (Tier 1) Tier 2 Continued Stay

H0019 U3 RESIDENTIAL CHILDREN’S SERVICES – LEVEL III

3. There has been relevant consumer and family progress toward crisis resolution and progress

clearly and directly related to resolving the factors, which warranted admission to crisis support, have been observed and documented, but treatment goals have not been reached.

4. It has been documented that the consumer has made no progress toward treatment goals nor has progress been made toward alternative placement (less restrictive or more restrictive care) but the care plan has been modified to introduce further evaluation of consumer needs and other appropriate interventions and treatment options.

Discharge Criteria 1. Appropriate placement has been located which

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meets the child’s treatment and care needs as outlined in the treatment plan.

2. The crisis, which necessitated placement has abated, and the child has returned to a level of functioning that allows reintegration into their previous care setting.

3. The child exhibits symptoms and functional impairment that cannot be treated safely and effectively in the crisis support setting and which necessitates more restrictive care (e.g.

inpatient).

Service Exclusions

1. The consumer is over 18 years of age (or 21 years of age if remained in DHHR custody).

2. No individual fee for Clinic or Rehabilitation service may be billed while this code is being utilized.

Clinical Exclusions

1. The consumer is considered a danger to himself or others.

2. The severity of the clinical issues/symptoms precludes provision of services in this level of care.

Documentation

1. There must be a permanent clinical record maintained;

2. The record must contain a Behavior Health Clinic/Rehabilitation Services Authorization for Services form signed by a physician within three (3) business days of admission, and indicating the need for Crisis Support;

3. The record must contain the client’s individual treatment plan;

4. Documentation must include the following:

behavioral observations of the child, record of the child’s participation including specific times of program participation, identification of the crisis support service components provided, and medication administration records.

5. A sign-in/sign-out sheet in each member’s record that indicates the date and time a youth departs from the site and the date and time they return to the site. The reason for the absence must be noted and the notation must be signed and dated by an agency staff.

Additional Service Criteria:

1. T1017 (Targeted Case Management) may be provided and billed.

2. *Service still subject to edits which limit length of stay to 90 days (no more than two (2) consecutive authorizations.

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3. * 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 authorization period.

4. 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.

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H0004 HO IP Behavioral Health Counseling, Professional, Individual

Definition: Face-to-face, structured intervention, (i.e., psychotherapy, specialty therapies, family preservation intervention, etc.) to improve an individual’s cognitive processing and/or functional abilities. The intent of this type of intervention is to focus on the dynamics of a consumer’s problem, (i.e., the cause of the individual’s impairments; resolution of intrapsychic/interpersonal conflicts;

elicit a change in behavior patterns; and to produce change toward identifiable goals) in an intensive program setting. Interventions are grounded in a specific and identifiable theoretical base, which provides a framework for assessing change. Any therapeutic interventions applied must be performed by a minimum of a master’s level therapist using generally accepted practice of therapies recognized by national accrediting bodies for psychology, psychiatry, counseling and social work. Certified Addictions Counselors (CAC’s) are considered credentialed to provide H0004 HO (Individual/Family Therapy) but only when directly addressing Substance Abuse Treatment issues. To provide therapy in other treatment areas, the Certified Addictions Counselor must be credentialed by the applicable accrediting bodies of their professional discipline.

Under this procedure code, conjoint or family therapy may occur with other individuals with a significant relationship to the consumer (e.g. spouse, parent, child, sibling, etc.). These individuals may participate in therapy to the extent it is helpful to the progress of the consumer; however, such participation by significant others is not reimbursable as a separate activity.

NOTE: This procedure code may only be utilized by providers who have an approved intensive program. The number of units approved for this service within a specified time period for the approved provider will be authorized when the consumer meets medical necessity criteria for the intensive program.

Service Tier Tier 3

Target Population MH, SA, MR/DD, A & C Medicaid Option Clinic/Rehabilitation

Initial Authorization

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

NOTE: The specific Intensive Program must be specified in the free-text field so appropriate units may be assigned.

Re-Authorization

Tier 3 data submission is required for additional units during or after the initial authorization period by any provider previously utilizing the benefit for the same consumer.

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Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

Admission Criteria

1. Consumer has a behavioral health diagnosis, -and-

2. Consumer demonstrates intrapsychic or interpersonal conflicts and/or need to change behavior patterns, -and-

3. The specific impairment(s) to be addressed can be delineated, -and-

4. Intervention is to focus on the dynamics of consumers’ problems, -and-

5. Interventions are grounded in a specific and identifiable theoretical base which provides a framework for assessing change, -and-

6. The consumers’ treatment plan reflects the need for the service.

Continuing Stay Criteria

1. The service is necessary and appropriate to meet the consumer’s need as identified on the treatment plan.

2. Progress notes document consumer’s progress relative to goals identified in the Service Plan but treatment goals have not yet been achieved.

Discharge Criteria

1. Consumer/ family request discharge or consumer refuses treatment.

2. Goals of the consumer’s treatment plan have been substantially met.

3. Transfer to another service is warranted by change in consumer’s condition.

4. There is no outlook for improvement with the continuation of this service.

Service Exclusions None

Clinical Exclusions

1. There is a lack of social support systems so that a more intensive level of service is needed.

2. There is no outlook for improvement with this level of service.

3. Severity of impairment precludes provision of the service on an outpatient basis.

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Documentation

This shall consist of an activity note describing the type of service/activity provided and relationship of the service /activity to an objective(s) in the treatment plan. The documentation must include the place of service; 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 time.

Treatment strategies and objectives utilizing individual therapeutic interventions shall be included in the individual’s master treatment plan and in an individual therapeutic intervention plan which expands on the more generalized objective in the master treatment plan.

Additional Service Criteria:

1. Service must be delivered by a therapist with at least a master’s degree and who is licensed (or under supervision) by a recognized national/state accrediting body for psychology, psychiatry, counseling or social work at a level which allows provision of this clinical service.

2. Certified Addictions Counselors (CAC’s) are credentialed to provide Individual/Family Therapy but only when addressing Substance Abuse Treatment issues and/or when their level of licensure specifically allows provision of this service.

3. The provider must have an approved intensive program per the protocol developed by APS and the consumer must meet the identified target population and admission/continued stay criteria.

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H0004 HO HQ IP Behavioral Health Counseling, Professional, Group Definition: Group Therapy is a face-to-face, structured intervention (i.e., psychotherapy, specialty therapies, etc.) in a group setting to improve an individual’s cognitive processing and/or functional abilities. The intent of the type of intervention is to focus on the dynamics of consumers’ problems (i.e. the cause of the individual’s impairments; resolution of intrapsychic/interpersonal conflicts; eliciting a change in behavior patterns; and to otherwise produce change toward identifiable goals) in an intensive program setting. These activities are carried out within a group context where the therapist engages the group dynamics in terms of peer relationships, common problems focus, and mutual support to promote progress for individual consumers.

Interventions are grounded in a specific and identifiable theoretical base, which provides a framework for assessing change. Any therapeutic intervention applied must be performed by a minimum of a master’s level therapist using generally accepted practice of therapies recognized by national associations for psychology, psychiatry, counseling and social work. Certified Addictions Counselor’s (CAC’s) are considered to be credentialed to provide H0004 HO HQ (Group Therapy), but only when directly addressing Substance Abuse Treatment issues. To provide therapy in other treatment areas the Certified Addictions Counselor must be credentialed by the applicable accrediting bodies of their professional discipline.

Service Tier Tier 3

Target Population MH, SA, MR/DD, A & C Medicaid Option Clinic/Rehabilitation

Initial Authorization

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

NOTE: The specific Intensive Program must be specified in the free-text field so appropriate units may be assigned.

Re-Authorization

Tier 3 data submission is required for additional units during or after the initial authorization period by any provider previously utilizing the benefit for the same consumer.

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Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

Admission Criteria

1. Consumer has a behavioral health diagnosis, -and-

2. Consumer demonstrates intrapsychic or interpersonal conflicts and/or needs to change behavior patterns, -and-

3. The specific impairment to be addressed can be delineated, -and-

4. Intervention is to focus on the dynamics of a consumer’s problem, -and-

5. Interventions are grounded in a specific and identifiable theoretical base which provides a framework for assessing change, -and-

6. The consumer’s treatment plan reflects the need for the service.

Continuing Stay Criteria

1. The service is necessary and appropriate to meet the consumer’s need as identified on the treatment plan.

2. Progress notes document consumer’s progress relative to goals identified in the treatment plan but treatment goals have not yet been achieved.

Discharge Criteria 1. Consumer/ family request discharge or refuse treatment.

2. Goals of the consumer’s treatment plan have been substantially met.

3. Transfer to another service is warranted by change in consumer’s condition.

Service Exclusions None

Clinical Exclusions

1. There is a lack of social support system so that a more intensive level of service is needed.

2. There is no outlook for improvement with the level of service.

3. Severity of impairment precludes provision of the service on an outpatient basis.

Documentation

Documentation shall consist of an activity note describing the type of service/activity provided and the relationship of the service/activity to an objective(s) in the treatment plan. Such documentation must include: place of the service, date of the service, and the actual time spent providing the service. The actual time spent must be documented by listing the start and stop times.

Treatment strategies and objectives utilized in therapeutic groups shall be included in the

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individual’s master treatment plan and in a therapeutic group intervention plan which expands on the more generalized objectives in the master treatment plan.

Additional Service Criteria:

2. Certified Addictions Counselors (CAC’s) are credentialed to provide Group Therapy but only when addressing Substance Abuse Treatment issues and/or when their level of licensure specifically allows provision of this service.

3. It is expected that the service will be provided at a frequency of no less than twice a month or as indicated on the treatment plan as a part of an approved plan of phasing out this service (may be less than twice a month).

4. Group size must be limited to a maximum of twelve (12) persons per group. The provider must have an approved intensive program per the protocol developed by APS and the consumer must meet the identified target population and admission/continued stay criteria.

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H0004 IP Behavioral Health Counseling, Supportive, Individual

Definition: Face-to-face intervention which is intended to provide support to maintain consumer progress towards identified goals and to assist individuals in their day-to-day management and problem solving as part of an intensive program setting.

This service utilizes basic counseling techniques and must be included in the consumer’s treatment plan. This service must be provided in the clinic setting, for the clinical option but can be provided in a variety of settings under the Rehabilitation Option. The service must be provided on a scheduled basis by designated staff with the exception of unscheduled crisis activities noted below.

It is expected that this service will be provided on an as needed basis, but may be as infrequent as once every 60 days. Staff other than licensed professional counselors must be qualified by their agencies with a minimum training in counseling techniques.

Service Tier Tier 3

Target Population MH, SA, MR/DD, A & C Medicaid Option Clinic/Rehabilitation

Initial Authorization

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

NOTE: The specific Intensive Program must be specified in the free-text field so appropriate units may be assigned.

Re-Authorization

Tier 3 data submission is required for additional units during or after the initial authorization period by any provider previously utilizing the benefit for the same consumer.

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

Admission Criteria

1. Consumer has a behavioral health diagnosis, -and-

2. Consumer has a need to be assisted with day-to-day management and problem solving to help them maintain progress toward identified goals,

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and-

3. Consumer’s treatment plan reflects the need for the service.

Continuing Stay Criteria

1. Service continues to be needed to maintain consumer’s progress towards identified goals and to assist individuals in their day-to-day management and problem solving.

2. Activity notes document the consumer’s progress relative to the objective on the treatment plan but treatment goals have not yet been achieved.

Discharge Criteria

1. Consumer/ family request discharge or refuses treatment.

2. Goals of the consumers treatment plan have been substantially met.

3. Transfer to another service is warranted by change in consumer’s condition.

Service Exclusion None

Clinical Exclusions

1. There is a lack of social support system so that a more intensive level of service is needed.

2. There is no outlook for improvement with this level of service.

3. Severity of impairment precludes the provision of service at this level of care.

Documentation

Documentation shall consist of an activity note describing the type of service/activity provided and relationship of the service/activity to an objective in the treatment plan.

The documentation must include the place of service, date of service, and the actual time spent providing the service, and the outcome of the counseling intervention. The actual time spent must be documented by listing the start and stop times.

Additional Service Criteria:

1. Service must be delivered by a licensed professional or staff credentialed by the agency.

2. Service must be provided on a scheduled basis by designated staff (except in cases of unscheduled crisis activities).

3. Service must be provided face-to-face.

4. It is expected that this service will be provided on an as needed basis, but may be as infrequent as once every 60 days.

5. The provider must have an approved intensive program per the protocol developed by APS and the consumer must meet the identified target population and admission/continued stay criteria.

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H0004 HQ IP Behavioral Health Counseling, Supportive, Group

Definition: Face-to-face intervention with a group of consumers, which is intended to provide support to maintain consumers at their current level of functioning and to assist individuals in their day-to-day management and problem solving as part of an intensive program setting. The group is structured around a peer relationship and/or problem focus common to all the participants such that they gain insight, problem solving assistance and mutual support under the guidance and direction of a qualified staff person who facilities and mediates the group dynamics as appropriate to achieve therapeutic outcomes.

This service utilizes basic therapeutic techniques and must be included in the consumer’s treatment plan. This service must be provided in a clinic setting for the Clinic Option but may be provided in a variety of settings under the Rehabilitation Option.

Service Tier Tier 3

Target Population MH, SA, MR/DD, A & C Medicaid Option Clinic/Rehabilitation

Initial Authorization

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

NOTE: The specific Intensive Program must be specified in the free-text field so appropriate units may be assigned.

Re-Authorization

Tier 3 data submission is required for additional units during or after the initial authorization period by any provider previously utilizing the benefit for the same consumer.

Units determined by individual intensive service program approved by APS.

Unit = 15 minutes

Admission Criteria

1. Consumer has a behavioral health diagnosis, -and-

2. Consumer has a need to be assisted with day-to-day management and problem solving and to

In document CLINIC, REHABILITATION, TARGETED CASE MANAGEMENT OPTIONS AND BHHF CONTRACT PROVIDERS (Page 129-144)