Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-024 - Behavioral Health Transformation

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
ARKids First-B
221.100 ARKids First-B Medical Care Benefits
			 7-1-17
Listed below are tiie covered services for the ARKids First-B
				program. Tliis chart also includes benefits, whether Prior Authorization or a
				Primary Care Physician (PCP) referral is required, and specifies the
				cost-sharing requirements.
Program Services
Benefit Coverage and Restrictions
Prior
Authorization/ PCP Referral*
Co-payment/ Coinsurance/ Cost Sharing
						  Requirement**
Ambulance (Emergency Only)
Medical Necessity
None
$10 per trip
Ambulatory Surgical Center
Medical Necessity
PCP Referral
$10 per visit
Audioiogical Services (only Tympanometry, CPT procedure
						  code 92567, when the diagnosis is within the ICD ranqe (View
ICD
codes.))
Medical Necessity
None
None
Certified Nurse-Midwife
Medical Necessity
PCP Referral
$10 per visit
Chiropractor
Medical Necessity
PCP Referral
$10 per visit
Dental Care
Routine dental care and orthodontia services
None - PA for inter-periodic screens and orthodontia
						  services
$10 per visit
Durable Medical Equipment
Medical Necessity $500 per state fiscal year (July 1
						  through June 30) minus the coinsurance/cost-share. Covered items are listed in
						  Section 262.120
PCP Referral and Prescription
10% of Medicaid allowed amount per DME item
						  cost-share
Emergency Dept. Services
Emergency
Medical Necessity
None
$10 per visit
Non-Emergency
Medical Necessity
PCP Referral
$10 per visit
Assessment
Medical Necessity
None
$10 per visit
Family Planning
Medical Necessity
None
None
Federally Qualified Health Center (FQHC)
Medical Necessity
PCP Referral
$10 per visit
Home Health
Medical Necessity (10 visits per state fiscal year
						  (July 1 through June 30)
PCP Referral
$10 per visit
Hospital, Inpatient
Medical Necessity
PA on stays over 4 days if age 1 or over
10% of first inpatient day
Hospital, Outpatient
Medical Necessity
PCP refen-al
$10 per visit
Inpatient Psychiatric Hospital and Psychiatric
						  Residential Treatment Facility
Medical Necessity
PA & Certification of Need is required prior to
						  admittance
10% of first inpatient day
Immunizations
All per protocol
None
None
Laboratory & X-Ray
Medical Necessity
PCP Refen-al
$10 per visit
Medical Supplies
Medical Necessity Benefit of $125/mo. Covered supplies
						  listed in Section 262.110
PCP Prescriptions
PA required on supply amounts exceeding $125/mo
None
Mental and Behavioral Health, Outpatient
School-Based Mental Health
Medical Necessity Medical Necessity
PCP Refen-al PA on treatment services
PA Required (See Section 250.000 of the School-Based
						  Mental Health provider manual.)
$10 per visit $10 per visit
Nurse Practitioner
Medical Necessity
PCP Refen-al
$10 per visit
Physician
Medical Necessity
PCP refen-al to specialist and inpatient professional
						  services
$10 per visit
Podiatry
Medical Necessity
PCP Referral
$10 per visit
Prenatal Care
Medical Necessity
None
None
Prescription Drugs
Medical Necessity
Prescription
Up to $5 per prescription (Must use generic, if
						  available)***
Preventive Health Screenings
All per protocol
PCP Administration or PCP Referral
None
Rural Health Clinic
Medical Necessity
PCP Refen-al
$10 per visit
Speech Therapy
Medical Necessity
PCP Referral
$10 per visit
4 evaluation units (1 unit
Authorization
=30 min) per state fiscal
required on
year
extended benefit of
4 therapy units (1 unit=15 min) daily
services
Occupational
Medical Necessity
PCP Referral
$10 per visit
Therapy
4 evaluation units (1 unit = 30 min) per state fiscal
						  year
Authorization required on extended benefit of
4 therapy units (1 unit =15 min) daily
services
Physical Therapy
Medical Necessity
PCP Referral
$10 per visit
4 evaluation units (1 unit = 30 min) per state fiscal
						  year
Authorization required on extended benefit of
4 therapy units (1 unit =15 min) daily
services
Substance Abuse Treatment Services (SATS)
Medical Necessity
Psychiatrist or Physician Prescription (See Section
						  221.000 of SATS manual)
$10 per visit
Prior Authorization required for all substance abuse
						  treatment services, except codes H0001 &T1007 when billed with no modifier.
						  Codes H0001 & T1007 require prior authorization when billed with a modifier
						  (See Section 231.100 of SATS manual).
Prior Authorization required on extended benefit of
						  services (See Section 230.000 of SATS manual)
Vision Care
Eye Exam
One (1) routine eye exam (refraction) every 12
						  months
None
$10 per visit
Eyeglasses
One (1) pair every 12 months
None
None
"Refer to your Arkansas Medicaid specialty provider manual for
				prior authorization and PCP referral procedures.
"ARKids First-B beneficiary cost-sharing is capped at 5% of the
				family's gross annual income.
""ARKids First-B beneficiaries will pay a maximum of $5.00 per
				prescription. The beneficiary will pay the provider the amount of co-payment
				that the provider charges non-Medicaid purchasers up to $5.00 per
				prescription.
221.200
			 Exclusions 7-1-17
Services Not Covered for ARKids First-B
				Beneficiaries:
Audiological Services; EXCEPTION, Tympanometry, CPT procedure
				code
92567,
when the diagnosis is within the ICD range.
				(
View
ICD
codes
.)
Child Health Management Services (CHMS)
Child Health Services/Early and Periodic Screening, Diagnosis
				and Treatment (EPSDT)
Developmental Day Treatment Clinic Services (DDTCS)
Diapers, Underpads and Incontinence Supplies
Domiciliary Care
End Stage Renal Disease Services
Hearing Aids
Hospice
Hyperalimentation
Non-Emergency Transportation
Nursing Facilities
Orthotic Appliances and Prosthetic Devices
Personal Care
Private Duty Nursing Services
Rehabilitation Therapy for Chemical Dependency
Rehabilitative Services for Children
Rehabilitative Services for Persons with Physical Disabilities
				(RSPD)
Targeted Case Management Ventilator Services
211.000 Introduction 7-1-17
Medicaid (Arkansas l\/ledical Assistance Program) is designed
				to assist eligible Medicaid beneficiaries in obtaining medical care within the
				guidelines specified in Section 1 of this manual. Reimbursement will be made
				for allowed services rendered by a Medicaid enrolled provider within the
				Medicaid Program limitations as outlined in Section 11 of this manual.
The transition process to eliminate the Rehabilitative Services
				for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health
				Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS)
				Program is contingent upon the approval of the implementation of the Outpatient
				Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP
				and SATS programs will begin transitioning to the Outpatient Behavioral Health
				Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June
				30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or
				SATS provider for services provided after June 30, 2018.
202.200 Residential Treatment Facilities
			 7-1-17
To enroll as a freestanding residential treatment center or as
				a residential treatment unit within an inpatient psychiatric hospital, the
				inpatient psychiatric provider must meet both of the conditions listed
				below:
A. The provider must meet the
			 child and adolescent standards of the Joint Commission on Accreditation of
			 Healthcare Organizations (JCAHO) and be accredited by JCAHO.
B. Any provider located within Arkansas must
			 be licensed by the Arkansas Department of Human Services as a psychiatric
			 residential treatment facility.
203.100 Facility-Based Community
			 Reintegration Program 7-1-17
The Facility-Based Community Reintegration Program is designed
				to serve as an intermediate level of care between inpatient psychiatric
				facilities and outpatient services. To enroll as a freestanding Facility-Based
				Community Reintegration Program unit or as a Facility-Based Community
				Reintegration Program unit within an inpatient psychiatric hospital, the
				inpatient psychiatric provider must meet all of the conditions listed
				below:
A. The provider must meet the
			 child and adolescent standards of the Joint Commission on Accreditation of
			 Healthcare Organizations (JCAHO) and be accredited by JCAHO.
B. Any provider located within Arkansas must
			 be licensed by the Arkansas Department of Human Services as a Facility-Based
			 Community Reintegration Program.
This manual, the Inpatient Psychiatric Services for Under Age
				21 Provider Manual, shall govern all aspects of services provided as well as
				claim submissions for beneficiaries of the Facility-Based Community
				Reintegration Program.
211.000 Scope 7-1-17
Inpatient psychiatric services covered by the Arkansas Medicaid
				Program must be provided:
A. By an
			 inpatient psychiatric provider enrolled in the Arkansas Medicaid
			 Program;
B. By an enrolled
			 inpatient psychiatric provider selected by the beneficiary;
C. To eligible Arkansas Medicaid
			 beneficiaries only after receipt of a primary care physician (PCP) referral
			 except in cases of emergency;
D. To
			 eligible Arkansas Medicaid beneficiaries who have a certification of need
			 issued by the facility-based and independent teams that the beneficiary meets
			 the criteria for inpatient psychiatric services;
E. To eligible Arkansas Medicaid
			 beneficiaries who have a prior authorization;
F. To eligible Arkansas Medicaid
			 beneficiaries before the beneficiary reaches age 21 or, if the beneficiary was
			 receiving inpatient psychiatric services at the time he or she reached age 21,
			 services may continue until the beneficiary no longer requires the services or
			 the beneficiary becomes 22 years of age, whichever comes first and
G. Under the direction of a physician
			 (contracted physicians are acceptable).
A standardized independent assessment will determine
				eligibility for Inpatient Psychiatric Services for Persons Under Age 21. The
				standardized independent assessment must be perfonned by an independent
				entity.
The independent assessment will contain additional criteria and
				questions, which will be asked based upon results from the independent
				assessment to detennine eligibility for Inpatient Psychiatric Sen/ices for
				Persons Under Age 21. Acute inpatient psychiatric care will not require an
				independent assessment.
The standardized independent assessment must be conducted at
				least every 12 months by an independent assessor in consultation with the
				beneficiary and anyone the beneficiary requests to participate in the
				standardized independent assessment. The standardized independent assessment
				will also take into consideration information obtained from behavioral health
				service providers that are providing services to the beneficiary.
A beneficiary must be referred to the independent assessment
				entity to evaluate whether the beneficiary meets the eligibility criteria for
				Inpatient Psychiatric Services for Persons Under Age 21. The following are
				allowable methods of referral to receive a standardized independent assessment
				for determination of eligibility for Inpatient Psychiatric Services for Persons
				Under Age 21;
A. Triggerfrom claims
			 data/l\/IMiS claims data
B.
			 Referral from counseling level services provider
C. Referral from physician (including those
			 in acute settings, mobile crisis units)
D. An individual determined to be medically
			 fragile due to behavior health needs
E. Refenal from the Division of Children and
			 Family Services (DCFS)/the Division of Youth Services (DYS) when they are the
			 legal guardian of the beneficiary
F. Referral/court order from the court
			 system/justice system
G. Referral
			 from care coordination entity
A re-assessment can be requested by the direct behavioral
				health service provider or the care coordination entity if the direct
				behavioral health service provider or care coordination entity determines the
				beneficiary's needs are not being met or the beneficiary is not benefitting
				from the Inpatient Psychiatric Services for Persons Under Age 21 being
				provided.
The independent assessor vi/ill contact the beneficiary to be
				assessed within 48 hours of referral and will complete the fece-to-face
				assessment within 14 calendar days. For identified priority populations, the
				independent assessor will contact the beneficiary to
be
assessed within 24 hours of notification from the beneficiary's
				provider and will complete the assessment within 7 days of the notification.
				Examples of priority population include, but are not to be limited to:
A. Youth involved in the juvenile justice
			 system
B. Individuals involved in
			 the foster care system
C.
			 Individuals discharged from acute hospital stays
D. Individuals discharged from crisis
			 residential stays
E. Adults
			 involved in the criminal justice system
F. Clients identified and refen-ed by the
			 Division of Behavioral Health Services (DBHS)
212.100 Covered Locations 7-1-17
Inpatient psychiatric services are covered by Ari[LESS
				THAN]ansas Medicaid only when provided in:
A. An inpatient psychiatric
			 hospital
B. A residential treatment
			 unit within a psycliiatric tiospital
C. A residential treatment center
			 (freestanding)
D. A Sexual Offender
			 Program
E. A Facility-Based
			 Community Reintegration Program
221.801 Attestation of Facility Compliance
			 7-1-17
Each psychiatric residential treatment facility and
				Facility-Based Community Reintegration Program that provides inpatient
				psychiatric services to individuals under age 21 must attest, in writing, that
				the facility is in compliance with the Centers for Medicare and Medicaid
				Service (CMS) standards governing the use of restraint and seclusion. This
				attestation must be signed by the facility director.
A. Current Medicaid Providers
A facility with a current provider agreement with the Medicaid
				agency must provide a letter of attestation no later than July 21st of each
				year. Attestations must be sent to each state Medicaid agency (SMA) where the
				PRTF has established a provider agreement.
Exceptions:
1. If July
			 21 St occurs on a weekend or holiday, the attestation is due on the first
			 business day following the weekend or holiday and
2. If the letter of attestation is not
			 received by the due date, the provider will be given 30 calendar days to submit
			 it. If it is not received by the 30th day after the due date, the provider will
			 be terminated from participation in the Arkansas Medicaid Program.
Attestation letters must be sent to the Medicaid Provider
				Enrollment Unit.
View or print the contact information for
				the Medicaid Provider Enrollment Unit.
B. New Medicaid Provider
			 Applicants
A facility enrolling as a Medicaid provider must meet this
				requirement at the time it executes a provider agreement with the Medicaid
				agency.
221.802
			 Federal Provider Identification Numbers 7-1-17
A federal provider identification number is assigned to each
				provider who meets the attestation requirement. The identification numbers for
				PRTFs and Facility-Based Community Reintegration Programs will have five digits
				and one letter. The first two digits identify the state in which the facility
				is located. This number is then followed by the letter L and then by three
				digits and is numbered according to the order in which a facility was
				identified.
A. Federal provider
			 numbers are assigned by the State Medicaid agency (SMA).
B. A provider number is coded based on where
			 the PRTF or Facility-Based Community Reintegration Program is physically
			 located.
221.803 Roles
			 and Responsibilities for the Reporting of Deaths, 7-1-17
Serious Injuries and Attempted Suicides
The interim process for reporting deaths will follow a similar
				process as currently in place for the death reporting process for hospitals.
				The roles and responsibilities of the appropriate entities are outlined
				below.
A. PRTFs and Facility-Based
			 Community Reintegration Programs
1. Report to
			 the SMA, no later than close of business the next business day, ail deaths,
			 serious injuries, and attempted suicides via fax at (501) 682-6171.
2. Report to the CMS regional office (RO) all
			 deaths no later than close of business the next business day after the
			 resident's death. Death reporting information should be reported to CMS at
			 (214) 767-4434.
3. Document in the
			 resident's record that the death was reported to the CMS regional
			 office.
B. CMS Regional
			 Office (RO)
1. The regional office should
			 receive the report directly from the PRTF or Facility-Based Community
			 Reintegration Program. Pursuant to
			 42 CFR
			 483.374(b)(1), the report
			 must include the name of the resident, a description of the occurrence, and the
			 name, street address and telephone number of the fecility.
2. The CMS regional office should make sure
			 the survey agency (SA) has received the report. The SA is responsible for
			 carrying out the investigation in conjunction with instructions from the State
			 Medicaid agency.
3. Since the PRTF
			 or Facility-Based Community Reintegration Program is responsible for reporting
			 to the agencies listed previously in addition to the CMS RO, the regional
			 office should obtain the completed investigation from the SA,
4. The report should be received from the
			 PRTF or Facility-Based Community Reintegration Program, according to
			 42 CFR
			 483.374(c)(1), no later than
			 close of business the next business day after the resident's death.
5. The CMS regional office will send the
			 death report to the CMS central office (CMS CO).
C. CMS Central Office (CO)
The CMS CO is responsible for maintaining a central log of the
				death infomiation reported from the CMS RO.
221.804 PRTF and Facility-Based Community
			 Reintegration Program Staff 7-1-17
Education and Training
The facility must require staff to have ongoing education,
				training and demonstrated knowledge of:
A. Techniques to identify staff and resident
			 behaviors, events and environmental factors that may trigger emergency safety
			 situations;
B. The use of
			 nonphysical intervention skills, such as de-escalation, mediation conflict
			 resolution, active listening, and verbal and observational methods, to prevent
			 emergency safety situations; and
C.
			 The safe use of restraint and the safe use of seclusion, including the ability
			 to recognize and respond to signs of physical distress in residents who are
			 restrained or in seclusion.
1. Certification
			 in the use of cardiopulmonary resuscitation, including periodic
			 recertification, is required.
2.
			 Individuals who are qualified by education, training and experience must
			 provide staff training.
3. Staff
			 training must include training exercises in which staff members successfully
			 demonstrate in practice the techniques they have learned for managing emergency
			 safety situations.
4. The staff
			 must be trained and demonstrate competency before participating in an emergency
			 safety intervention.
5. The staff
			 must demonstrate their competencies as specified in paragraph A of this section
			 on a semiannual basis and their competencies as specified in paragraph B of
			 this section on an annual basis.
6.
			 The facility must document in the staff personnel records that the training and
			 demonstration of competency were successfully completed. Documentation must
			 include the date training was completed and the name of persons certifying the
			 completion of training.
7. All
			 training programs and materials used by the facility must be available for
			 review by CMS, the SMA and the State SA.
250.500 Facility-Based Community
			 Reintegration Program 7-1-17
The per diem rates for Facility-Based Community Reintegration
				Programs are established at the lesser of:
1) the center's budgeted cost per day which
			 includes the professional component or
2) a $245 per day upper limit (cap). This is
			 a prospective rate with no cost settlement.
The budgeted per diem cost is calculated from the annual
				budget, which ail Facility-Based Community Reintegration Program providers are
				required to submit for the upcoming state fiscal year (July 1st through June
				30th). Annual budgets are due by April 30th. Should April 30th fall on a
				Saturday, Sunday or state or federal holiday, the due date shall be the
				following business day. Failure to submit the budget by April 30th may result
				in the suspension of reimbursement until the budget is submitted. Rates are
				calculated annually and are effective for dates of service occurring during the
				state fiscal year for which the budgets have been prepared.
New providers are required to submit a full year's annual
				budget for the current state fiscal year (July 1st through June 30th) at the
				time of enrollment. This budget is used to set their rate at the lesser of the
				budgeted allowable cost per day or the upper limit (cap) of $245 per
				day.
251.000 Cost
			 Report 7-1-17
inpatient psychiatric hospitals, residential treatment units,
				Facility-Based Community Reintegration Programs and Sexual Offender Programs
				must submit an annual or partial period hospital cost report to the Arkansas
				Medicaid Program. Providers with less than a full 12-month reporting period are
				also required to submit a hospital cost report for the shorter period. Cost
				reports are due no later than five months following the close of the provider's
				fiscal year end. Extensions will not be allowed. Failure to file the cost
				report within the prescribed period may result in suspension of reimbursement
				until the cost report is filed.
Providers will submit all required hospital cost reports
				and budgets In accordance with Medicare Principles of Reasonable Cost
				Reimbursement Identified In 42 CFR, Part 413. All cost settlements will be made
				using these principles.
262.100 Inpatient Psychiatric Revenue Codes
			 7-1-17
Revenue Code
Revenue Code Description
114
Inpatient Psychiatric Hospital only
124
Residential Treatment Center only
128
Sexual Offender Program only
129
Residential Treatment Unit only
TBD
Facility-Based Community Reintegration Program
						  only
201.000 Introduction 7-1-17
Medicaid (IViedical Assistance) is designed to assist eligible
				Medicaid beneficiaries in obtaining medical care witliin tlie guidelines
				specified in Section I of this manual. Rehabilitative Services for Persons with
				Mental Illness (RSPMI) are covered by Medicaid when provided to eligible
				Medicaid beneficiaries by enrolled providers.
RSPMI may be provided to eligible Medicaid beneficiaries at all
				provider facility certified sites. Acceptable allowable places of service are
				found in the service definitions located in Section 252.110.
The transition process to eliminate the Rehabilitative Services
				for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health
				Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS)
				Program is contingent upon the approval of the implementation of the Outpatient
				Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP
				and SATS programs will begin transitioning to the Outpatient Behavioral Health
				Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June
				30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or
				SATS provider for services provided after June 30, 2018.
211.000 Introduction 7-1-17
Medicaid (Arkansas IVIedical Assistance Program) is designed to
				assist eligible Medicaid beneficiaries in obtaining medical care within the
				guidelines specified in Section I of this manual. Reimbursement will be made
				for allowed services rendered by a Medicaid enrolled provider within the
				Medicaid Program limitations as outlined in Section II of this manual.
The transition process to eliminate the Rehabilitative Services
				for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health
				Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS)
				Program is contingent upon the approval of the implementation of the Outpatient
				Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP
				and SATS programs will begin transitioning to the Outpatient Behavioral Health
				Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June
				30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or
				SATS provider for services provided after June 30, 2018.
201.000 Introduction 7-1-17
Medicaid (IVIedical Assistance) is designed to assist eligible
				Arkansas Medicaid beneficiaries in obtaining medical care within the guidelines
				specified in Section t of this manual. Substance Abuse Treatment Services
				(SATS) are covered by Arkansas Medicaid when provided to eligible Arkansas
				Medicaid beneficiaries by enrolled providers.
SATS may be provided to eligible Arkansas Medicaid
				beneficiaries at all provider facility certified sites. Allowable places of
				service are found in Section 252.200.
The transition process to eliminate the Rehabilitative Services
				for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health
				Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS)
				Program is contingent upon the approval of the implementation of the Outpatient
				Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP
				and SATS programs will begin transitioning to the Outpatient Behavioral Health
				Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June
				30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or
				SATS provider for services provided after June 30, 2018.
202.100 Requirements for Certification of
			 Provider Staff or Contracted 7-1-17
Professionals Who Provide School-Based Mental Health
				Services
School-Based Mental Health Services provider employees and
				contractors will provide services only in those areas in which they are
				licensed or credentialed.
School-Based Mental Health Services provider employees and
				contractors will be under the supervision and jurisdiction of the school
				district and/or ESC and will provide services twelve months of each
				year.
School district and Educational Services Cooperative (ESC)
				mental health provider employee and contractor requirements are as
				follows:
A. Licensed Certified Social
			 Worker (LCSW)
1. The LCSW must possess a
			 master's degree in social work from a graduate school of social work accredited
			 by the Council on Social Work Education (CSWE).
2. The LCSW must be state licensed and
			 certified to practice as a licensed certified social worker in the State of
			 Arkansas and in good standing with the Arkansas Social Work Licensing
			 Board.
3. The LCSW must provide to
			 the school district or ESC proof of two (2) years post-licensure experience
			 treating children and adolescents with mental illness.
4. The LCSW shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
NOTE: A licensed certified social worker employed or
				contracted with the school
district or ESC may not be enrolled in the Targeted Case
				Management (TCM) Program. He or she must choose only one of these programs in
				which to participate.
B. Licensed Master Social Worker (LMSW)
1. The LMSW must have a master's degree from
			 an accredited social work program in an accredited institution approved by the
			 Council on Social Work Education (CSWE).
2. The LMSW must be state licensed and
			 certified to practice as a licensed master social worker in the State of
			 Arkansas and in good standing with the Arkansas Social Work Licensing
			 Board.
3. The LMSW must work under
			 the supervision of an LCSW.
4. The
			 LMSW shall not provide services beyond those for which he or she has been
			 trained and are within his or her scope of practice and licensure.
5. The LMSW shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
NOTE: A licensed certified social worker employed or
				contracted with the school
district or ESC may not be enrolled in the Targeted Case
				Management (TCM) Program. He or she must choose only one of these programs in
				which to participate.
C. Licensed Professional Counselor (LPC)
1. The LPC must have received a graduate
			 (master's) degree that is primarily professional counseling in content from a
			 regionally accredited institution of higher education. The LPC must have
			 accumulated at least 48 graduate semester hours to meet the academic and
			 training content standard established by the Arkansas Board of Examiners in
			 Counseling.
2. The LPC has three
			 (3) years of supervised full-time experience in professional counseling
			 acceptable to the Arkansas Board of Examiners in Counseling. One (1) year of
			 experience may be gained for each 30 graduate semester hours earned beyond the
			 master's degree provided that the hours are clearly related to the field of
			 counseling and are acceptable to the Board. In no case may the applicant have
			 less than one (1) year of supervised professional experience.
3. The LPC must be licensed as a licensed
			 professional counselor and be in good standing with the Arkansas Board of
			 Examiners in Counseling.
4. The LPC
			 must meet all licensure requirements as set forth in Arkansas Code Annotated
			 §
											17-27-301
			 for licensed Professional Counselors (LPC).
5. The LPC must provide proof to the school
			 district or ESC of two (2) years post-licensure experience treating children
			 and adolescents with mental illness.
6. The LPC shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
D. Licensed Associate Counselor (LAC)
1. The LAC must be licensed as a licensed
			 associate counselor and in good standing with the Arkansas Board of Examiners
			 in Counseling.
2. The LAC must meet
			 all licensure requirements as held forth in Arkansas Code Annotated §
											17-27-302.
3. The LAC may practice only under direct
			 supervision of an LPC.
4. The plan
			 for supervision of the LAC must be approved by the Board of Examiners in
			 Counseling prior to any actual performance of counseling on the part of the
			 LAC.
5. The LAC must provide proof
			 to the school district or ESC of two (2) years post-licensure experience
			 treating children and adolescents with mental illness.
6. The LAC shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
7. The LAC
			 shall provide to the school district or ESC a copy of his or her supervision
			 plan including the name and license number of his or her supervising LPC before
			 the LAC provides any service for which he or she is required to be under the
			 supervision of a LPC.
E.
			 Licensed School Psychology Specialist (LSPS)
1. The LSPS must possess a minimum of 60
			 graduate semester hours sixth year/specialist program with an appropriate
			 graduate degree from a North Central Accreditation for Teacher Education
			 (NCATE) accredited institution of higher learning or one authorized by the
			 Arkansas Department of Education.
2. The LSPS must hold a valid license from
			 the Arkansas State Board of Education and be licensed as a school psychology
			 specialist.
3. The LSPS must have
			 completed an internship that consists of one academic year or its equivalent
			 with a minimum of 1200 clock hours of supervised experience, at least 600 of
			 which must be in a school setting.
4. The LSPS shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
F. Licensed Psychological Examiner (LPE)
1. The LPE must have two (2) academic years
			 of graduate training in psychology,
including a master's degree from an accredited educational
				institution recognized by the Arkansas Board of Examiners in Psychology as
				maintaining satisfactory standards or, in lieu tinereof, such training and
				experience as the Board shall consider equivalent.
2. The LPE must be licensed as a licensed
			 psychological examiner and be in good standing with the Arkansas Board of
			 Examiners in Psychology.
3. The LPE
			 shall provide to the school district or ESC the name and licensure number of
			 his or her supervising psychologist before the LPE provides any service for
			 which he or she is required to be under the supervision of a psychologist
			 licensed by the Arkansas Board of Examiners in Psychology.
4. The LPE shall not provide services beyond
			 those for which he or she has been trained and are within his or her scope of
			 practice and licensure.
G. Psychologist
1. The psychologist must have at least two
			 (2) years of experience in psychology of a type considered by the Board to be
			 qualifying in nature with at least one (1) of those years being postdoctoral
			 work.
2. The psychologist must be
			 licensed as a psychologist by the Arkansas Board of Examiners in
			 Psychology.
3. The psychologist
			 shall not provide services beyond those for which he or she has been trained
			 and are within his or her scope of practice and licensure.
211.000 Introduction
			 7-1-17
Medicaid (Arkansas Medical Assistance Program) is designed to
				assist eligible beneficiaries in obtaining medical care within the guidelines
				specified in Section I of the manual. Reimbursement will be made for allowed
				services rendered by a Medicaid-enrolled school-based provider within the
				Medicaid Program limitations as outlined in this manual.
211.300 Primary Care Physician (PCP) Referral
			 7-1-17
Each beneficiary who receives School-Based Mental Health
				Services can receive a limited amount of services. Once those limits are
				reached, a Primary Care Physician (PCP) referral or Patient-Centered Medical
				Home (PCMH) approval will be necessary to continue treatment. This referral or
				approval must be retained in the beneficiary's medical record.
A beneficiary can receive three (3) School-Based Mental Health
				Services before a PCP/PCMH referral is necessary. No services will be allowed
				to be provided without appropriate PCP/PCMH referral. The PCP/PCMH refen-al
				must be kept in the beneficiary's medical record.
The Patient-Centered Medical Home (PCMH) will be responsible
				for coordinating care with a beneficiary's PCP or physician for School-Based
				Mental Health Services. Medical responsibility for beneficiaries receiving
				School-Based Mental Health Services shall be vested in a physician licensed in
				Arkansas.
The PCP refen-al or PCMH authorization for School-Based Mental
				Health Services will serve as the prescription for those services.
See Section I of this manual for the PCP procedures. A PCP
				referral is generally obtained prior to providing service to Medicaid-eligible
				children. However, a PCP is given the option of providing a referral after a
				service is provided. If a PCP chooses to make a referral after a service has
				been provided, the referral must be received by the SBMH provider no later than
				45 calendar days after the date of service. The PCP has no obligation to give a
				retroactive referral.
The SBMH provider may not file a claim and will not be
				reimbursed for any services provided that require a PCP referral unless the
				referral is received.
212.000 Scope 7-1-17
The School-Based Mental Health Services program consists of a
				range of mental health diagnostic, therapeutic, rehabilitative or palliative
				services provided by the employees and contractors described in Section 202.100
				of this manual to Medicaid-eligible beneficiaries (including ARKids B) under
				age twenty-one (21) suffering from psychiatric conditions as described in the
				cun-ent allowable American Psychiatric Association Diagnostic and Statistical
				Manual (DSM).
Medicaid-covered school-based mental health services may be
				provided only when:
A. Referred, in
			 writing or verbally, by a Medicaid-enrolled physician. See Section 212.100 for
			 details.
B. Provided to Medicaid
			 recipients under age 21.
C.
			 Provided to outpatients.
D.
			 Provided by School-Based Mental Health Services provider employees or
			 contractors.
E. A comprehensive
			 assessment indicates the need for services (see Section 212.200 for
			 details).
F. Included in a
			 treatment plan.
213.000
			 Exclusions 7-1-17
The following are non-covered School-Based Mental Health
				Services:
A. Services provided in a
			 supervised living or residential treatment facility.
B. Educational sen/ices.
C. Telephone contacts with the patient or
			 telephone contacts with the collateral in regard to the beneficiary.
D. Services to individuals with developmental
			 disabilities that are non-psychiatric in nature, except for testing
			 purposes.
E. Inpatient Hospital
			 Services.
"Inpatient" means a patient who has been admitted to a medical
				institution on recommendation of a physician or dentist and is receiving room,
				board and professional services in the institution on a continuous
				24-hour-a-day basis, or who is expected by the institution to receive room,
				board and professional services for a 24-hour period or longer even though it
				later develops that the patient dies, is discharged or is transfen-ed to
				another facility and does not actually stay in the institution for 24
				hours.
F. Inpatient
			 Psychiatric Services.
See E. above for definition of inpatient.
G. A School-Based Mental Health Services
			 provider will not be reimbursed for the same procedure code for a service
			 provided on the same date of sen/ice as services provided by a Counseling Level
			 Outpatient Behavioral Health Services Provider or Outpatient Behavioral Health
			 Services Provider certified by the Division of Behavioral Health
			 Services.
214.000
			 Covered Services 7-1-17
Outpatient Services
Fifteen-minute units, unless otherwise stated.
Outpatient Behavioral Health Services must be billed on a
				per-unit basis, as reflected in a daily total, per beneficiary, per
				service.
One (1) unit =
8-24 minutes
Two (2) units =
25-39 minutes
Three (3) units =
40-49 minutes
Four (4) units =
50-60 minutes
Time spent providing services for a single beneficiary may be
				accumulated during a single, 24-hour calendar day. Providers may accumulatively
				bill for a
single date of service, per beneficiary, per Outpatient
				Behavioral Health service
. Providers are not allowed to
				accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Outpatient
				Behavioral Health service, based on the established procedure codes. No
				rounding is allowed.
The sum of the days' time, in minutes, per service will
				detennine how many units are allowed to be billed. That number must not be
				exceeded. The total number of minutes per service must be compared to the
				following grid, which detemiines the number of units allowed.
One (1) unit =
&-24 minutes
Two (2) units =
25-39 minutes
Three (3) units =
40-49 minutes
Four (4) units =
50-60 minutes
In a single-claim transaction, a provider may bill only for
				service time accumulated within a single day for a single beneficiary. There is
				no "carryover" of time from one day to another or from one beneficiary to
				another,
Documentation in the beneficiary's record must reflect exactly
				how the number of units is determined.
No more than four (4) units may be billed for a single hour per
				beneficiary or provider of the service.
Refer to Section 272.100 of this manual for descriptions of
				procedure codes that are reimbursable by Arkansas Medicaid for School-Based
				Mental Health providers.
219.000 Utilization Review 7-1-17
The Utilization Review Section of the Arl[LESS THAN]ansas
				Medicaid Program has the responsibility for assuring quality medical care for
				its beneficiaries along with protecting the integrity of both state and federal
				funds supporting the Medical Assistance Program.
219.100 Record Reviews 7-1-17
The Division of Medical Services (DMS) of the Ari[LESS
				THAN]ansas Department of Human Services (DHS) has contracted with an
				independent contractor to perfomi on-site inspections of care (IOC) and
				retrospective reviews of outpatient mental health services provided by
				Outpatient Behavioral Health Services providers.
View or print
				current contractor contact information
. The reviews are conducted
				by licensed mental health professionals and are based on applicable federal and
				state laws, rules and professionally recognized standards of care.
228.130 Retrospective Reviews
			 7-1-17
The Division of IVledical Services (DI\/1S) of tine Arkansas
				Department of Human Services has contracted with a Quality Improvement
				Organization (QIO) or QlO-like organization to perfomi retrospective
				(post-payment) reviews of outpatient mental health sen/ices provided by
				Outpatient Behavioral Health providers.
View or print current
				contractor contact information.
The reviews will be conducted by licensed mental health
				professionals who will examine the medical record for compliance with federal
				and state laws and regulations.
228.131 Purpose of a Review 7-1-17 The
			 purpose of a review is to:
A. Ensure that
			 services are delivered in accordance with the treatment plan and confomi to
			 generally accepted professional standards.
B. Evaluate the medical necessity of services
			 provided to Medicaid beneficiaries.
C. Evaluate the clinical documentation to
			 detemiine if it is sufficient to support the sen/ices billed during the
			 requested period of authorized services.
D. Safeguard the Arkansas Medicaid program
			 against unnecessary or inappropriate use of services and excess payments in
			 compliance with
			 42 CFR
			 §
											456.3(a).
229.000 Medicaid Beneficiary
			 Appeal Process 7-1-17
If an adverse decision is received, the beneficiary may request
				a fair hearing of the denial decision.
The appeal request must be in writing and received by the
				Appeals and Hearings Section of the Department of Human Services within thirty
				days of the date on the letter explaining the denial of services.
229.200 Recoupment Process 7-1-17
The Division of Medical Services (DMS), Utilization Review
				Section (UR) is required to initiate the recoupment process for all claims that
				the current contractor has denied because the records submitted do not support
				the claim of medical necessity.
Ari[LESS THAN]ansas Medicaid will send the provider an
				Explanation of Recoupment Notice that will include the claim date of service,
				Medicaid beneficiary name and ID number, service provided, amount paid by
				Medicaid, amount to be recouped, and the reason the recoupment is
				initiated.
272.100
			 School-Based Mental Health Services Procedure Codes 7-1-17
The following is a list of covered services available in the
				School-Based Mental Health Sen/ices Program. Practitioners enrolled as
				school-based mental health services provider personnel may provide the services
				on this list according to their scope of practice as identified by the
				licensure requirements.
272.110 Mental Health Diagnosis 7-1-17
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
90791
Psychiatric diagnostic evaluation (with no
						  medical services)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Mental Health Diagnosis is a clinical service for the
						  purpose of determining the existence, type, nature and appropriate treatment of
						  a mental illness or related disorder as described in the current allowable DSM.
						  This service may include time spent for obtaining necessary information for
						  diagnostic purposes. The psychodiagnostic process may include, but is not
						  limited to, a psychosocial and medical history, diagnostic findings, and
						  recommendations. This service must include a face-to-face component and will
						  serve as the basis for documentation of modality and issues to be addressed
						  (Plan of Care). Services must be congruent with the age and abilities of the
						  beneficiary, client-centered and strength-based, with emphasis on needs as
						  identified by the beneficiary and provided with cultural competence.
* Date of service
* Start and stop times of the face-to-face encounter
						  with the beneficiary and the interpretation time for diagnostic
						  formulation
* Place of service
* Identifying information
* Referral reason
* Presenting problem(s), history of presenting
						  problem(s) including duration, intensity and response(s) to prior
						  treatment
* Culturally- and age-appropriate psychosocial history
						  and assessment
* Mental status/clinical observations and
						  impressions
* Current functioning plus strengths and needs in
						  specified life domains
* DSM diagnostic impressions to include all axes
* Treatment recommendations
* Goals and objectives to be placed in Plan of
						  Care
* Staff signature/credentials/date of signature
NOTES
UNIT
BENEFIT LIMITS
This service may be billed for face-to-face contact as
						  well as for time spent obtaining necessary information for diagnostic purposes;
						  however, this time may NOT be used for development or submission of required
						  paperwork processes (i.e. treatment plans, etc.).
Encounter
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of benefits can be requested): 1
APPLICABLE POPULATIONS
SPECIAL BILLJNG INSTRUCTIONS
Children and Youth
Outpatient Behavioral Health Services Providers
						  cannot bill 90791 on same date of service
ALLOWED MODE(S) OF DELIVERY
TIER
Face-to-face
School-Based Mental Health
ALLOWABLE PERFORMING PROVIDER
PLACE OF SERVICE
* Licensed Certified Social Worker (LCSW)
* Licensed Master Social Worker (LMSW)
* Licensed Professional Counselor (LPC)
* Licensed Associate Counselor (LAC)
* Licensed School Psychology Specialist
03
(LSPS)
* Licensed Psychological Examiner (LPE)
* Psychologist
* School-Based Mental Health Services provider
						  employees or contractors will provide services only in those areas in which
						  they are licensed or credentialed.
272.120 Psychological Evaluation
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
96101
Psychological testing (includes psychodiagnostic
						  assessment of emotionality, intellectual abilities, personality and
						  psychopathology, e.g. MMPI, Rorschach®, WAIS®), per hour of the
						  psychologist's or physician's time, both face-to-face time administering tests
						  to the patient and time interpreting these test results and preparing the
						  report.
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Psychological evaluation for personality assessment
						  includes psychodiagnostic assessment of a beneficiary's emotional, personality,
						  and psychopathology, e.g. MMPI, Rorschach®, and WAIS®. Psychological
						  testing is billed per hour both face-time administering tests and time
						  interpreting these tests and preparing the report. This service may reflect the
						  mental abilities, aptitudes, interests, attitudes, motivation, emotional and
						  personality characteristics of the beneficiary. Medical necessity for this
						  service is met when:
the service is necessary to establish a differential
						  diagnosis of behavioral or psychiatric conditions;
* history and symptomatology are not readily
						  attributable to a particular psychiatric diagnosis; or questions to be answered
						  by the evaluation could not be resolved by a psychiatric/diagnostic interview,
						  observation in therapy or an assessment for level of care at a mental health
						  facility.
* Date of service
* Start and stop times of actual encounter with
						  beneficiary
* Start and stop times of scoring, interpretation and
						  report preparation
* Place of service
* Identifying information
* Rationale for referral
* Presenting problem(s)
* Culturally- and age-appropriate psychosocial history
						  and assessment
* Mental status/clinical observations and
						  impressions
* Psychological tests used, results, and
						  interpretations, as indicated
* DSM diagnostic impressions to include all axes
* Treatment recommendations and findings related to
						  rationale for service and guided by test results
* Staff signature/credentials/date of
						  signature(s)
NOTES
I---------
.
--------------------------------------------------------------
UNIT
BENEFIT LIMITS
60 minutes
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of benefits can be requested): 8
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children and Youth
ALLOWED MODE{S) OF DELIVERY
TIER
Face-to-face
School-Based Mental Health
ALLOWABLE PERFORMING PROVIDERS
PLACE OF SERVICE
* Licensed Psychological Examiner (LPE)
* Psychologist
03
272.130 Interpretation of Diagnosis
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
90887
Interpretation or explanation of results of psychiatric
						  or other medical examinations and procedures, or other accumulated data to
						  family or other responsible persons, or advising them how to assist
						  patient
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Interpretation of Diagnosis is a direct service
						  provided for the purpose of interpreting the results of psychiatric or other
						  medical exams, procedures or accumulated data. Services may include diagnostic
						  activities and/or advising the beneficiary and his/ her family. Consent forms
						  may be required for family or significant other involvement. Services must be
						  congruent with the age and abilities of the beneficiary, client-centered and
						  strength-based, with emphasis on needs as identified by the beneficiary and
						  provided with cultural competence.
* Start and stop times of face to face encounter with
						  beneficiary and/or parents or guardian
* Date of service
* Place of service
* Participants present and relationship to
						  beneficiary
* Diagnosis
* Rationale for and objective used that must coincide
						  with the goals and objectives placed in Plan of Care
* Participant(s) response and feedback
* Staff signature/credentials/date of
						  signature(s)
NOTES
UNIT
BENEFIT LIMITS
For beneficiaries under the age of 18, the time may be
						  spent face-to-face with the beneficiary, the beneficiary and the parent(s) or
						  guardian(s) or alone with the parent(s) or guardian(s). For beneficiaries over
						  the age of 18, the time may be spent face-to-face with the beneficiary and the
						  spouse, legal guardian or significant other.
Encounter
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of
272.140 Marital/Family Behavioral Health
			 Counseling with Beneficiary
Present
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
90847
Family psychotherapy with patient present (conjoint
						  psychotherapy)
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Marital/Family Behavioral Health Counseling with
						  Beneficiary Present is a face-to-face treatment provided to one or more family
						  members in the presence of a beneficiary. Services must be congruent with the
						  age and abilities of the beneficiary, client-centered and strength-based, with
						  emphasis on needs as identified by the beneficiary and provided with cultural
						  competence. Services are designed to enhance insight into family interactions,
						  facilitate inter-family emotional or practical support and to develop
						  alternative strategies to address familial issues, problems and needs. Services
						  pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse
						  condition. Additionally, tobacco cessation counseling is a component of this
						  service.
Date of Service
Start and stop times of actual encounter with
						  beneficiary and spouse/family
* Place of service
Participants present and relationship to
						  beneficiary
* Diagnosis and pertinent interval history
Brief mental status of beneficiary and observations of
						  beneficiary with spouse/family
Rationale for, and description of treatment used, that
						  must coincide with the master treatment plan and improve the impact the
						  beneficiary's condition has on the spouse/family and/or improve marital/family
						  interactions between the beneficiary and the spouse/family.
* Beneficiary and spouse/family's response to treatment
						  that includes cun-ent progress or regression and prognosis
* Any changes indicated for the master treatment plan,
						  diagnosis, or medication(s)
Plan for next session, including any homework
						  assignments and/or crisis plans
Staff signature/credentials/date of signature
HIPAA compliant release of Information, completed,
						  signed and dated
NOTES
UNIT
BENEFIT LIMITS
Natural supports may be included in these sessions if
						  justified in service documentation. Only one beneficiary per family per therapy
						  session may be billed.
Encounter
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of benefits can be requested): 12
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children and Youth
ALLOWED MODE(S) OF DELIVERY
TIER
Face-to-face
School-Based Mental Health
ALLOWABLE PERFORMING PROVIDERS
PLACE OF SERVICE
* Licensed Certified Social Worker (LCSW)
* Licensed IVIaster Social Worker (LMSW)
* Licensed Professional Counselor (LPC)
* Licensed Associate Counselor (LAC)
* Licensed School Psychology Specialist (LSPS)
* Licensed Psychological Examiner (LPE)
* Psychologist
* School-Based Mental Health Services provider
						  employees or contractors will provide services only in those areas in which
						  they are licensed or credentialed.
03
272.150 Crisis Intervention
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
H2011.HA
Crisis intervention service, per 15 minutes
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Crisis Intervention is unsclieduled, immediate,
						  short-term treatment activities provided to a Medicaid-eligible beneficiary
						  wlio is experiencing a psychiatric or behavioral crisis. Services are to be
						  congruent with the age, strengths, needed accommodation for any disability, and
						  cultural framework of the beneficiary and his/her family. These services are
						  designed to stabilize the person in crisis, prevent further deterioration and
						  provide immediate indicated treatment in the least restrictive setting. (These
						  activities include evaluating a Medicaid-eiigible beneficiary to determine if
						  the need for crisis services is present.)
* Date of service
* Start and stop time of actual encounter with
						  beneficiary and possible collateral contacts with caregivers or informed
						  persons
* Place of service
* Specific persons providing pertinent information in
						  relationship to beneficiary
* Diagnosis and synopsis of events leading up to crisis
						  situation
* Brief mental status and observations
* Utilization of previously established psychiatric
						  advance directive or crisis plan as pertinent to current situation OR rationale
						  for crisis intervention activities utilized
* Beneficiary's response to the intervention that
						  Includes current progress or regression and prognosis
* Clear resolution of the current crisis and/or plans
						  for further services
* Development of a clearly defined crisis plan or
						  revision to existing plan
* Staff signature/credentials/date of
						  signature(s)
NOTES
UNIT
BENEFIT LIMITS
A psychiatric or behavioral crisis is defined as an
						  acute situation in which an individual is experiencing a serious mental illness
						  or emotional disturbance to the point that the beneficiary or others are at
						  risk for imminent harm or in which to prevent significant deterioration of the
						  beneficiary's functioning.
This service can be provided to beneficiaries that have
						  not been previously assessed or have not previously received behavioral health
						  services.
The provider of this service MUST complete a Mental
						  Health Diagnosis (90791) within 7 days of provision of this service. If the
						  beneficiary needs more time to be stabilized, this must be noted in the
						  beneficiary's medical record and the Division of Medical Services Quality
						  Improvement Organization (QIC) must be notified.
15 minutes
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of benefits can be requested): 72
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children and Youth
ALLOWED MODE(S) OF DELIVERY
|TIER _ '
Face-to-face
School-Based Mental Health
ALLOWABLE PERFORMING PROVIDERS
PLACE OF SERVICE
* Licensed Certified Social Worker (LCSW)
* Licensed Master Social Worker (LMSW)
* Licensed Professional Counselor (LPC)
* Licensed Associate Counselor (LAC)
* Licensed School Psychology Specialist (LSPS)
* Licensed Psychological Examiner (LPE)
* Psychologist
* School-Based Mental Health Services provider
						  employees or contractors will provide services only in those areas in which
						  they are licensed or credentialed.
03
272.160 Individual Behavioral Health
			 Counseling
CPT®/HCPCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
90832 90834 90837
90832: psychotherapy, 30 min 90834: psychotherapy, 45
						  min 90837: psychotherapy, 60 min
SERVICE DESCRIPTION
MINIMUM DOCUMENTATION REQUIREMENTS
Individual Behavioral Health Counseling is a
						  face-to-face treatment provided to an individual in an outpatient setting for
						  the purpose of treatment and remediation of a condition as described in the
						  current allowable DSM. Services must be congruent with the age and abilities of
						  the beneficiary, client-centered and strength-based with an emphasis on needs
						  as identified by the beneficiary and provided with cultural competence. The
						  treatment service must reduce or alleviate identified symptoms related to
						  either (a) Mental Health or (b) Substance Abuse and maintain or improve level
						  of functioning, and/or prevent deterioration. Additionally, tobacco cessation
						  counseling is a component of this service.
* Date of service
* Start and stop times of face-to-face encounter with
						  beneficiary
* Place of service
* Diagnosis and pertinent interval history
* Brief mental status and observations
* Rationale and description of the treatment used that
						  must coincide with objectives on the master treatment plan
* Beneficiary's response to treatment that includes
						  current progress or regression and prognosis
* Any revisions indicated for the master treatment
						  plan, diagnosis or medication(s)
* Plan for next individual therapy session, including
						  any homework assignments and/or advanced psychiatric directive
* Staff signature/credentials/date of signature
NOTES
UNIT
BENEFITLIMITS
Services provided must be congruent with the objectives
						  and interventions articulated on the
90832: 30 minutes 90834: 45 minutes
DAILY MAXIMUM OF UNITS THAT MAY BE
most recent treatment plan. Services must be consistent
						  with established behavioral healthcare standards. Individual psychotherapy is
						  not permitted with beneficiaries who do not have the cognitive ability to
						  benefit from the service.
90837: 60 minutes
BILLED: 90832:1 90834:1 90837: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension
						  of benefits can be requested):
12 units
APPLICABLE POPULATIONS
SPECIAL BILLING INSTRUCTIONS
Children and Youth
A provider may only bill one individual
						  counseling/psychotherapy code per day per beneficiary. A provider cannot bill
						  any other individual counseling/psychotherapy code on the same date of service
						  for the same beneficiary.
ALLOWED MODE(S) OF DELIVERY
TIER
Face-to-face
School-Based Mental Health
ALLOWABLE PERFORMING PROVIDERS
PLACE OF SERVICE (POS)
* Licensed Certified Social Worker (LCSW)
* Licensed Master Social Worker (LMSW)
* Licensed Professional Counselor (LPC)
* Licensed Associate Counselor (LAC)
* Licensed School Psychology Specialist (LSPS)
* Licensed Psychological Examiner (LPE)
* Psychologist
* School-Based Mental Health Services provider
						  employees or contractors will provide services only in those areas in which
						  they are licensed or credentialed.
03