Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.11-017 - Substance Abuse Treatment Services (SATS) New-11

Current through Register Vol. 49, No. 6, June, 2024
Section II
Substance Abuse Treatment
			 Services
200.000
SUBSTANCE ABUSE
			 TREATMENT SERVICES (SATS) GENERAL INFORMATION
201.000
Introduction
Medicaid (Medical Assistance) is designed to assist eligible
				Arkansas Medicaid beneficiaries in obtaining medical care within the guidelines
				specified in Section I 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.
201.100
Electronic Signatures
Medicaid will accept electronic signatures provided the electronic signatures
			 comply with Arkansas Code
			 25-31-103.
202.000
Arkansas Medicaid
			 Participation Requirements for SATS
In order to ensure quality and continuity of care, all SATS
				providers approved to receive Arkansas Medicaid reimbursement for services to
				Arkansas Medicaid beneficiaries must meet specific qualifications for their
				services and staff. Providers with multiple service sites must enroll each site
				separately and reflect the actual service site on billing claims.
SATS providers must meet the Provider Participation and
				Enrollment requirements contained within Section 140.000 of this manual, as
				well as the following criteria, to be eligible to participate in the Arkansas
				Medicaid Program as a SATS provider.
A. Providers must be located within the State
			 of Arkansas.
B. A provider must be
			 certified by the Division of Behavioral Health Services (DBHS) as a SATS
			 provider, unless otherwise stated in this manual. (See Section 202.100 for
			 certification requirements.)
C. A
			 copy of the current DBHS certification as a SATS provider must accompany the
			 provider application and Arkansas Medicaid contract, unless otherwise stated in
			 this manual.
NOTE: For participation in the SATS Program, both the
				billing provider and the
performing provider must be certified by DBHS and
				enrolled in the Arkansas Medicaid program. Enrollment criteria are as
				follows:
BILLING PROVIDERS
- Arkansas Medicaid provider
				application and Arkansas Medicaid contract, along with the SATS certification
				issued by DBHS.
PERFORMING PROVIDERS
- Arkansas Medicaid provider
				application and Arkansas Medicaid contract, along with the SATS certification
				issued by DBHS AND a document verifying the employer/employee relationship
				between a certified SATS billing provider and the individual
				professional/paraprofessional. Documentation may be an employer/employee
				contract or a W-4 form.
EXCEPTION: Physicians and Advance Practice Nurses
enrolled in the Arkansas Medicaid Program
are not required to
				be certified by DBHS; however, they must verify their employer/employee
				relationship with a certified SATS billing provider as described above and
				submit a copy of their current professional license.
202.100
Certification
			 Requirements by the Division of Behavioral Health Services (DBHS)
SATS providers must furnish documentation of certification from
				the Division of Behavioral Health Services (DBHS) establishing that the
				provider is accredited in the delivery of substance abuse treatment services to
				be furnished by the Joint Commission on Accreditation of Healthcare
				Organizations (JCAHO), the Commission on Accreditation of Rehabilitation
				Facilities (CARF), the Council on Accreditation (COA) or other national
				accreditation approved by DBHS. Providers must meet all other certification
				requirements in addition to accreditation.
Certification requirements for SATS providers may be found
				at
www.arkansas.gov/dhs/dmhs/.
210.000
PROGRAM COVERAGE
211.000
Coverage of Services
Substance Abuse Treatment Services (SATS) are limited to
				providers who offer evidence-based practices of Substance Abuse Treatment
				Services as approved by the Division of Behavioral Health Services (DBHS). The
				provider must be certified as a SATS provider by DBHS, unless otherwise stated
				in this manual.
212.000
Quality Assurance
Each SATS provider must establish and maintain a quality
				assurance committee that will examine the clinical records for completeness,
				adequacy and appropriateness of care, quality of care and efficient utilization
				of provider resources. The quality assurance documentation should be filed
				separately from the clinical records.
213.000
Staff Requirements
Each SATS provider shall ensure that a Certified Clinical
				Supervisor (CCS) recognized by the Arkansas Substance Abuse Certification Board
				or a Registered Clinical Supervisor recognized by the Arkansas Board of
				Examiners of Alcoholism and Drug Abuse Counselors (BEADAC) is available to
				provide supervision of all clinical activities. SATS staff members must provide
				services only within the scope of their individual licensure and according to
				established policy in the SATS Medicaid program. It is the responsibility of
				the facility to credential each clinical staff member, specifying the areas in
				which he or she can practice based on training, experience and demonstrated
				competence. All staff must have a contractual or salaried employee relationship
				with the certified SATS provider.
The following are eligible to provide SAT services (see Section
				252.110-252.120) in the Arkansas Medicaid Program.
Contracted and salaried staff must meet all professional
				requirements as defined in the state licensing and certification laws relating
				to their respective professions. Professionals include the following:
1. Board certified or board eligible
			 Psychiatrist
2. Arkansas Medicaid
			 enrolled licensed Physician in the state of Arkansas
3. Advanced Practice Nurse (APN) who has a
			 collaborative agreement with a Physician licensed in the state of
			 Arkansas
4. Physician
			 Assistant
5. Licensed Alcoholism
			 and Drug Abuse Counselor (LADAC)
6.
			 Advanced Certified Alcoholism and Drug Abuse Counselor (ACADC)
7. Certified Co-Occurring Disorder
			 Professional - Diplomate Level (CCDP-D) With the addition of substance abuse
			 credentials (LADAC, ACADC, CCDP-D), the following may provide substance abuse
			 clinical services:
1. Licensed
			 Certified Social Worker (LCSW) and Licensed Master Social Worker (LMSW), which
			 must have approved supervision
2.
			 Licensed Professional Counselor (LPC) and Licensed Marriage and Family
			 Therapist (LMFT) and Licensed Associate Counselor (LAC), which must have
			 approved supervision
3.
			 Psychologist
4. Psychological
			 Examiner (LPE-I) licensed to practice independently
5. Psychological Examiner (LPE) under the
			 supervision of a Psychologist
Effective for dates of service on and after July 1, 2011, when
				a SATS provider files a claim with Arkansas Medicaid, the staff member who
				actually performed the service on behalf of the SATS provider must be
				identified on the claim as the performing provider. SATS staff members must be
				enrolled in the Arkansas Medicaid program and be identified on claims.
This action is taken in compliance with the federal Improper
				Payments Information Act of 2002 (IPIA),
				Public
				Law 107-300 and the resulting Payment Error Rate
				Measurement (PERM) program initiated by the Centers for Medicare and Medicaid
				Services (CMS).
Certain types of practitioners who perform services on behalf
				of a SATS provider are paraprofessionals that will be required to be certified
				by DBHS as a SATS paraprofessional and enroll in the Arkansas Medicaid program.
				The following persons may provide Substance Abuse Care Coordination (H0006)
				while under the supervision of a Certified Clinical Supervisor (CCS) recognized
				by the Arkansas Substance Abuse Certification Board or a Registered Clinical
				Supervisor recognized by the Arkansas Board of Examiners of Alcoholism and Drug
				Abuse Counselors (BEADAC):
1. Certified Alcohol and Drug Counselor
			 (CADC)
2. Certified Co-Occurring
			 Disorder Professional - Bachelors Level (CCDP-B)
3. Certified Co-Occurring Disorder
			 Professional - Associate Level (CCDP-A)
4. Licensed Associate Alcoholism and Drug
			 Abuse Counselor (LAADAC)
5.
			 Counselor in Training (CIT) as defined by ADAP licensing standards
214.000
Facility
			 Requirements
The administrator of the program shall be responsible for
				providing physical facilities that are structurally sound and meet all
				applicable federal, state and local regulations for adequacy of construction,
				safety, sanitation, health and compliance with the Americans with Disabilities
				Act.
215.000
Scope
A range of substance abuse treatment services is provided by a
				duly certified SATS provider to Medicaid-eligible beneficiaries with a
				substance abuse diagnosis, as described in the American Psychiatric Association
				Diagnostic and Statistical Manual (DSM-IV and subsequent revisions).
Substance Abuse Treatment Services are covered when:
A. Provided by qualified providers
B. Approved by the psychiatrist or physician
			 identified, contracted or employed by the SATS facility
C. Provided according to a written treatment
			 plan/plan of care
D. Provided to
			 outpatients only
E. In order to be
			 valid, the treatment plan/plan of care must:
1. Be prepared according to guidelines
			 developed and stipulated by the organization's accrediting body
2. Be signed and dated by the psychiatrist or
			 physician who certifies medical necessity
Services provided prior to the date of the psychiatrist's or
				physician's signature are not reimbursable through the SATS Program. Until the
				treatment plan is signed and dated by the psychiatrist or physician, no SATS
				are considered covered, other than Addiction Assessment - H0001.
The psychiatrist's or physician's signature is not valid
				without the date signed. The treatment plan must be signed by a psychiatrist or
				physician participating in the treatment of the beneficiary. The psychiatrist
				or physician provides supervision and oversight for all medical and treatment
				services provided by the agency. A psychiatrist or physician will supervise and
				coordinate all services as indicated in treatment plans. Medical responsibility
				shall be vested in the psychiatrist or physician.
216.000
SATS Program
			 Entry
Eligibility for the SATS Program will be determined by American
				Society of Addiction Medicine (ASAM) criteria.
Prior to providing treatment services, an Addiction Assessment
				for a new beneficiary (H0001) must be completed for each beneficiary considered
				for entry into a SATS Program.
The Addiction Assessment is a written evaluation that
				identifies and evaluates the nature and extent of the beneficiary's
				use/abuse/addiction to alcohol and/or other substances and identifies any
				co-morbid conditions. The Addiction Assessment must result in the assignment of
				a diagnostic impression and support effective treatment in the SATS Program.
				The Addiction Assessment also results in the patient placement recommendation
				for the treatment regimen appropriate to the condition and situation presented
				by the beneficiary. The Addiction Assessment must be available in the
				beneficiary's records.
The Addiction Assessment must be conducted face-to-face by a
				substance abuse professional qualified by licensure and experienced in the
				diagnosis of substance abuse and according to SATS Program policy guidelines.
				An Addiction Assessment must include the components set forth in the DBHS SATS
				Manual.
216.100
Primary Care Physician (PCP) Referral
A PCP referral is
NOT
required for SAT services.
				However, continuity of care and the medical home model is encouraged by
				Arkansas Medicaid.
217.000
Treatment Planning (T1007)
For each beneficiary entering the SATS Program, the treatment
				team must develop an individualized treatment plan. This consists of a written,
				individualized plan to treat, ameliorate, diminish, stabilize, or maintain
				remission of symptoms of substance abuse that threaten life, or cause pain or
				suffering, resulting in diminished or impaired functional capacity. The
				treatment plan must include goals and objectives based on individualized
				service needs identified in the completed Addiction Assessment. The treatment
				plan must be included in the beneficiary records and contain a written
				description of the treatment objectives for that beneficiary.
The treatment plan is a person-centered plan and developed in
				cooperation with the individual (parent or guardian if the individual is under
				18) to deliver specific addiction services to the individual to restore,
				improve or stabilize the individual's condition. The plan must be based on
				individualized service needs identified in the completed Addiction
				Assessment.
For each beneficiary served through the SATS Program, the
				treatment team must certify that the program can meet the beneficiary's needs,
				based on established program policy guidelines. This certification must be
				documented in the beneficiary record within 14 calendar days of the initial
				contact through treatment team signatures on the treatment plan/plan of care.
				The treatment team must include, at a minimum, a physician and an individual
				qualified, by licensure and experience, in diagnosis and treatment of substance
				abuse. Both criteria may be satisfied by the same individual, if
				qualified.
NOTE: All beneficiaries diagnosed with both a mental
				health and substance abuse diagnosis require an integrated treatment approach,
				including both mental health and substance abuse treatment. If the beneficiary
				is receiving services in both the RSPMI and SATS Program, the RSPMI provider
				will bill for the assessment, treatment planning, etc., and not the SATS
				provider. A provider cannot bill for both RSPMI and SATS assessments and
				treatment planning for the same beneficiary. A beneficiary receiving services
				in the RSPMI program may not have a separate treatment plan in the SATS
				Program. These billing rules apply to all providers involved in the mental
				health and substance abuse treatment for the beneficiary. Clinical records must
				be integrated to provide a cohesive treatment course with no duplication of
				services from one program to the next. Providers are required to share
				treatment documentation.
The treatment plan must also describe:
A. Beneficiary identification information,
			 including full name and address, date of birth, Medicaid ID number, effective
			 date of SATS eligibility (indicated by psychiatrist's or physician's signature
			 and the date signed on the treatment plan) and expiration date of the treatment
			 plan
B. The treatment regimen-the
			 specific individualized medical and remedial services, therapies and activities
			 determined and designed to meet the treatment objectives
C. A projected schedule for service
			 delivery-this includes the expected frequency and duration of each type of
			 planned therapeutic session or encounter
D. The credentials of personnel that will be
			 furnishing the services
E. A
			 projected schedule for completing reevaluations of the patient's condition and
			 updating the treatment plan
Substance Abuse services, other than the initial assessment,
				are not reimbursable prior to the development of the treatment plan, signed and
				dated by a psychiatrist or physician. The effective date of the treatment plan
				is the date of the psychiatrist's or physician's signature. The effective date
				and the expiration date must be reflected on the treatment plan. Medicaid
				expenditures paid for services rendered and billed prior to the date of the
				psychiatrist's or physician's signature on the treatment plan are subject to
				recoupment.
Provisional (no billable procedure code) and
				Comprehensive Treatment Plans (T1007)
At the time of the initial Addiction Assessment, a provisional
				treatment plan for the beneficiary is to be developed. This provisional
				treatment plan must be signed and dated by the professional who conducted the
				Addiction Assessment. The provisional treatment plan determines if the SAT
				services will meet the beneficiary's current needs. The provisional treatment
				plan also identifies placement recommendation for treatment regimen appropriate
				to the condition and situation presented by the beneficiary and referral into a
				service appropriate to effectively treat the condition(s) identified. The
				assessment process results in the assignment of a diagnostic impression if
				applicable, patient placement recommendation for treatment regimen appropriate
				to the condition and situation presented by the beneficiary, provisional
				treatment plan recommendations until the comprehensive treatment plan is
				completed (including physician signature and date) and referral to a service
				appropriate to effectively treat the condition(s) identified. This service may
				or may not be provided by a psychiatrist or physician.
If signed by a professional other than a psychiatrist or
				physician, the plan of care is not reimbursable and is considered a provisional
				plan of care. No later than 14 days from the development of the provisional
				plan of care, a comprehensive treatment plan must be developed and signed by a
				psychiatrist or physician. The development of the comprehensive treatment plan
				is reimbursable.
The provisional treatment plan may be used to request prior
				authorization for services; however, until the comprehensive treatment plan is
				signed and dated by the psychiatrist or physician (Treatment Planning - New
				Beneficiary - T1007), no SATS will be reimbursed.
The SATS comprehensive treatment plan must be completed and
				signed by a psychiatrist or physician prior to the delivery of any substance
				abuse outpatient services (other than the Addiction Assessment - H0001).
The SATS comprehensive treatment plan must be completed by a
				professional and approved by a psychiatrist or physician, within 14 calendar
				days of the beneficiary's first contact and must include the components set
				forth in the DBHS Licensure Standards for Alcohol and/or Other Drug Abuse
				Treatment Programs (Pg. 29: CTP1).
The comprehensive treatment plan developed for a new
				beneficiary may be effective for no more than one (1) year from the date of the
				psychiatrist's or physician's signature. The expiration date of the
				comprehensive treatment plan will be entered on the first page of the plan.
				Backdating treatment plans is not allowed and is subject to recoupment.
Periodic Revisions to the Treatment Plan (no billable
				procedure code)
While the comprehensive treatment plan may be effective for one
				(1) year from the date of the psychiatrist's or physician's signature, the plan
				may be revised at any time, based on need and medical necessity established
				through the prior authorization process.
A SATS treatment plan must be reviewed once every 90 days
				in order to continue providing SAT services through the Arkansas Medicaid
				program. The 90-day review must be documented in the beneficiary's medical
				file.
Subsequent revisions in the treatment plan will be approved in
				writing (signed and dated) by the psychiatrist or physician verifying continued
				medical necessity prior to services being rendered. All revisions to the
				treatment plan become effective on the date of the psychiatrist's or
				physician's signature next to the change on the treatment plan. Backdating
				treatment plans is not allowed and is subject to recoupment.
IMPLEMENTATION PLAN
The SATS provider must develop an implementation plan that
				ensures services are:
A.
			 Individualized to the beneficiary's unique circumstances
B. Provided in the least restrictive
			 environment possible
C. Developed
			 using a process that ensures participation of those concerned with the
			 beneficiary's welfare
D. Monitored
			 and revised as needed and substantiated according to program policy
E. Provided using a system that safeguards
			 the beneficiary's rights
F.
			 Documented with assurance that records will be maintained
NOTE: Each service included on the SATS treatment plan
				must be justified by the physician certifying medical necessity. This
				justification is based on medical necessity; the beneficiary's physical, mental
				and functional status; other support services available to the beneficiary and
				other factors deemed appropriate by the SATS provider and approved through the
				PA process.
Each SATS service must be provided according to the
				beneficiary's treatment plan. As detailed in the Arkansas Medicaid Program
				provider contract, providers may bill only after services are
				provided.
218.000
Exclusions
Services not covered under the SATS Program include, but are
				not limited to:
A. Room and board
			 residential costs
B. Educational
			 services
C. Telephone contacts with
			 beneficiary or collateral
D.
			 Transportation services, including time spent transporting a beneficiary for
			 services
(Reimbursement for SAT services is not allowed for the
				period of time the Medicaid beneficiary is in transport.)
F. SAT services that are
			 determined as not medically necessary
G. SAT services that duplicate integral and
			 inseparable parts of other Arkansas Medicaid services when provided on the same
			 date of service
219.000
Documentation
The SATS provider must develop and maintain sufficient written
				documentation to support each medical or remedial therapy, service, activity or
				session for which Medicaid reimbursement is sought. This documentation, at a
				minimum, must consist of:
A. Notes
			 individualized to the beneficiary and specific to the services provided
			 (Duplicated notes are not allowed.)
B. The date and actual time the services were
			 provided (Time frames may not overlap between services. All services must be
			 outside the time frame of other services.)
C. Name and credentials of the person who
			 provided the services
D. The
			 relationship of the services to the treatment regimen described in the
			 treatment plan/plan of care
E.
			 Updates describing the beneficiary's progress
F. For services that require contact with
			 anyone other than the beneficiary, evidence of conformance with HIPAA
			 regulations, including presence in documentation of specific authorizations, is
			 required.
Documentation must be legible and concise. The name and title
				of the person providing the service must reflect the appropriate professional
				level in accordance with the staffing requirements found in Section
				213.000.
All documentation must be available to representatives of the
				Division of Medical Services (DMS) at the time of an audit. All documentation
				must be available at the provider's place of business. No more than 30 days
				will be allowed after the date on the recoupment notice in which additional
				documentation will be accepted. Additional documentation will not be accepted
				after the 30-day period.
If more than one SATS service is provided on the same date of
				service, the documentation must specifically delineate items A through D above
				for each service billed. For audit purposes, the auditor must readily be able
				to discern which service was billed in a particular time period based upon
				supporting documentation for that particular billing.
A provider's failure to maintain sufficient documentation to
				support his or her billing practices may result in recoupment of Medicaid
				payment.
No documentation for SAT services, as with all Medicaid
				services, may be made in pencil.
220.000
Medical Necessity
All Substance Abuse Treatment Services must be medically
				necessary.
221.000
Prescription for SATS
Medicaid will not cover any SATS without a current prescription
				signed by a psychiatrist or physician. Prescriptions shall be based on
				consideration of the Addiction Assessment and Treatment Plan and an evaluation
				of the enrolled beneficiary (directly or through review of the medical records
				and consultation with the treatment staff). The prescription of the services
				will be documented by the psychiatrist's or physician's signature and date on
				the SATS treatment plan. Approval of all updates or revisions to the treatment
				plan must be documented by the psychiatrist's or physician's dated signature on
				the revised document. All beneficiaries diagnosed with both a mental health and
				substance abuse diagnosis require an integrated treatment approach including
				both mental health and substance abuse treatment. If the provider of the mental
				health treatment is the provider of the substance abuse treatment, the RSPMI
				provider will bill for the assessment, treatment planning, etc, and not the
				SATS. Providers cannot bill for both RSPMI and SATS assessments and treatment
				planning for the same beneficiary. Clinical records must be integrated to
				provide a cohesive treatment course with no duplication of services from one
				program to the next. When it is necessary for two separate SATS providers to be
				involved with treatment, the same billing rules apply. Providers are required
				to share treatment documentation as appropriate.
Services cannot begin prior to the date of the psychiatrist's
				or physician's signature on the treatment plan (except Addiction Assessment -
				H0001). Medicaid expenditures paid for services rendered and billed prior to
				the date of the psychiatrist's or physician's signature on the treatment plan
				are subject to recoupment.
222.000
Provider Reviews
The Utilization Review Section of the Arkansas Division of
				Medical Services has the responsibility for assuring quality medical care for
				beneficiaries, along with protecting the integrity of both state and federal
				funds supporting the Medical Assistance Program.
223.000
On-Site Inspections of Care
			 (IOC)
223.100
Purpose
			 of the Review
The on-site inspections of care of SATS providers are intended
				to:
A. Promote SAT services being
			 provided in compliance with federal and state laws, rules and professionally
			 recognized standards of care as outlined in the DBHS SATS supplemental
			 manual
B. Identify and clearly
			 define areas of deficiency where the provision of services is not in compliance
			 with federal and state laws, rules and professionally recognized standards of
			 care as outlined in the DBHS SATS supplemental manual
C. Require provider facilities to develop and
			 implement appropriate corrective action plans to remediate all deficiencies
			 identified
D. Provide
			 accountability that corrective action plans are implemented
E. Determine the effectiveness of implemented
			 corrective action plans
223.110
Provider Notification of IOC
			 7-1 -11
The provider will be notified no more than 48 hours before the
				scheduled arrival of the inspection team. It is the responsibility of the
				provider to provide a reasonably comfortable place for the team to work. When
				possible, this location will provide reasonable access to the outpatient care
				areas and the medical records.
223.120
Information Available Upon
			 Arrival of the IOC Team
The provider will make the following available to the IOC team
				upon arrival at the site:
A. Medical
			 records of Arkansas Medicaid beneficiaries who are identified by the
			 reviewer
B. One or more
			 knowledgeable administrative staff member(s) to assist the team
C. The opportunity to assess direct
			 outpatient care, which does not disrupt or distract from the actual provision
			 of care
D. Staff personnel records,
			 complete with hire dates, dates of credentialing and copies of current
			 licenses, credentials, criminal background checks, etc.
And, if identified as necessary to clarify specific chart-audit
				questions:
E. Written
			 policies, procedures and committee minutes
F. Data collected for Clinical
			 Administration, Clinical Services, Quality Assurance, Quality Improvement,
			 Utilization Review and Credentialing
G. Program descriptions, manuals, schedules,
			 staffing plans and evaluation studies
223.130
Cases Chosen for Review 7-1
			 -11
The cases are chosen by a case selection procedure that
				combines random sampling and cases identified as "high utilization" and
				"outliers."
A. High Utilizers are
			 beneficiaries who meet pre-defined levels of service utilization within an
			 identified period of time.
B.
			 Outliers are any providers or beneficiaries whose provision of services or
			 service utilization meets pre-defined criteria of variance from the
			 norm.
C. Cases chosen for review
			 for On-Site Inspections of Care (IOC) are subject to the purpose, policies and
			 procedures specified in Sections 224.100 (Purpose of the Review), 224.120
			 (Denial/Due Process), 224.130 (Reconsideration) and 224.140 (Recoupments).
The review period will be specified in the provider
				notification letter. The list of cases to be reviewed will be given to the
				provider upon arrival or chosen by the IOC team from a list for that location
				with a request for certain components of the records. The information requested
				includes, but is not limited to:
1.
			 Treatment plans (plan of care) and PoC reviews
2. Progress notes, including physician
			 notes
3. Physician orders and lab
			 results
4. Copies of records
The reviewer may request a copy of any record.
223.140
Program Activity Observation
The reviewer will observe at least one program activity.
223.150
Beneficiary/Family
			 Interviews
The provider is required to arrange interviews of Medicaid
				beneficiaries and family member(s) as requested by the reviewer, preferably
				with the beneficiaries whose records are being reviewed. If the beneficiaries
				whose records are being reviewed are not available, interviews will be
				conducted with beneficiaries on-site whose records are not scheduled for review
				and the records for those beneficiaries will be added to the review. Family
				members may be interviewed on-site or by telephone conference call.
223.160
Exit
			 Conference
The IOC team will conduct an exit conference summarizing their
				findings and recommendations. Providers are free to involve staff in the exit
				conference.
223.170
Written Reports
A written report of the inspection team's conclusions will be
				forwarded to the facility and to the Program Integrity Unit of the Division of
				Medical Services within 14 calendar days of the last day of inspection. The
				written report will clearly identify any area of deficiency that requires
				submission of a Corrective Action Plan.
223.180
Corrective Action Plans
The provider is required to submit a Corrective Action Plan
				designed to rectify any area of deficiency noted in the written report of the
				Inspection of Care review. The Corrective Action Plan must be submitted to the
				contracted utilization review agency within 30 calendar days of the date of the
				written report. The contractor will review the Corrective Action Plan and
				forward it, with recommendations, to the Program Integrity Unit of the Division
				of Medical Services.
223.190
Other Actions
Other actions that may be taken as part of the Inspection of
				Care include, but are not limited to:
A. Beneficiaries determined to no longer meet
			 medical necessity criteria for substance abuse services will no longer be
			 eligible for SATS.
B. Follow-up
			 Inspections of Care may be recommended by the contracted utilization review
			 agency and required by Division of Medical Services to verify the
			 implementation and effectiveness of corrective actions. Follow-up inspections
			 may be focused on the issues addressed by the Corrective Action Plan or may be
			 a complete re-Inspection of Care, at the sole discretion of the Division of
			 Medical Services.
C. Review by the
			 Program Integrity Unit of the Division of Medical Services.
224.000
Retrospective
			 Reviews
The Division of Medical Services of the Arkansas Department of
				Human Services has contracted with the Quality Improvement Organization
				(QIO-like), ValueOptions® to perform
				retrospective (post payment) reviews of outpatient mental health services
				provided by RSPMI providers. View or print ValueOptions® 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.
224.100
Purpose of the Review
The purpose of the review is to:
A. Evaluate the medical necessity of services
			 provided to Medicaid beneficiaries
B. Evaluate the clinical documentation to
			 determine if it is sufficient to support the services billed during the
			 requested period of authorized services
C. Ensure that the Arkansas Medicaid program
			 safeguards against unnecessary or inappropriate use of services and excess
			 payments in compliance with
			 42 CFR
			 456.3(a)
224.110
Cases Chosen for
			 Review
On a calendar quarterly basis, the contractor will select and
				review a statistically valid random sample of all SAT services billed and paid
				during the past three months (previous quarter). The written request for record
				copies will be posted on ProviderConnect and mailed to each provider along with
				instructions for submitting the medical record. The request will include the
				beneficiary's name, date of birth, Medicaid identification number, dates of
				service, type of service, date of request and the medical record. The
				provider(s) must submit the information to the contractor within 35 calendar
				days of the request date printed in the record request cover letter. If the
				requested information is not received within the 35-day timeframe, a medical
				necessity denial will be issued.
All medical records must be submitted to the contractor via
				fax, mail or ProviderConnect. View or print ValueOptions® information.When
				faxing or mailing records, send them to the attention of "Retrospective Review
				Team." Records will not be accepted via email.
224.120
Denial/Due Process
If the retrospective review results in a denial of services,
				the contractor will send a denial notification letter that outlines the
				rationale for the denial and includes instructions for requesting
				reconsideration. The denial notification letter will also be posted on
				ProviderConnect.
224.130
Reconsideration
A request for administrative reconsideration of the denial of
				services must be in writing and sent to the contractor within 35 calendar days
				of the denial. The request must include a copy of the denial letter and
				additional supporting documentation.
The deadline for receipt of the reconsideration request will be
				enforced pursuant to Sections 190.012 and 190.013 of this manual. A request
				received by the contractor within 35 calendar days of a denial will be deemed
				timely. Reconsideration requests must be submitted via fax, mail or
				ProviderConnect. Reconsideration requests will not be accepted via
				email.
If the request is received timely, the contractor will review
				the additional information and determine if the services can be approved. If
				approved, the contractor will reverse the previous denial. If the services were
				denied due to lack of medical necessity and the additional information
				submitted for reconsideration does not support medical necessity, the case will
				be referred to a physician for final determination.
The contractor may approve or deny all or part of the services.
				A written notification of the outcome of the reconsideration review will be
				mailed to all parties and posted on ProviderConnect. This notification will
				include a case-specific rationale for upholding or overturning the
				denial.
The decision of the contractor, upon reconsideration, is
				final.
224.140
Recoupments
The Division of Medical Services will initiate the recoupment
				process for all claims that the contractor has denied on retrospective
				review.
The Division of Medical Services 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
				Arkansas Medicaid, amount to be recouped and the reason for the
				recoupment.
230.000
PRIOR AUTHORIZATION (PA) AND EXTENSION OF BENEFITS
231.000
Introduction to Prior
			 Authorization and Extension of Benefits
The Division of Medical Services contracts with a utilization
				review agency to complete the prior authorization (PA) and extension of benefit
				processes.
A request for prior authorization for services to be provided
				to a foster child must specify that the request is for a foster child. A
				request for services to be provided to a child in the custody of the Division
				of Youth Services (DYS) must specify DYS custody.
231.100
Prior Authorization and
			 Extension of Benefits
Prior Authorization is required for all SAT services provided
				to Medicaid-eligible beneficiaries, except codes H0001 (no modifier) and T1007
				(no modifier). These two (2) codes represent the Addiction Assessment for the
				NEW patient and the comprehensive Treatment Planning for a NEW patient. These
				codes when billed with a modifier and all other SATS procedure codes require
				PA. Extension of benefits is available for beneficiaries under the age of 21
				and is required for all services when the maximum benefit for the service is
				exhausted. Yearly service benefits are based on the state fiscal year running
				from July 1 to June 30. Prior authorization and extension requests must be sent
				to the contracted utilization review agency for beneficiaries under the age of
				21. View or print ValueOptions® contact information.
Prior authorization requests must be sent to the contracted
				utilization review agency for all beneficiaries in the SATS Program. View or
				print ValueOptions® contact information.
Procedure codes requiring
				prior authorization:
National Codes
H0001
Required Modifier
U8
Service Title
Addiction Assessment - Established Beneficiary
T1007
U8
Treatment Planning - Established Beneficiary
H0006
Care Coordination
H0047
Multi-Person (Family) Group Counseling
H2019
Individual Counseling
H0005
Group Counseling
T1006
Marital/Family Counseling
H2010
Medication Management
Note: The initial (provisional) plan of care for the
				beneficiary developed during the
Addiction Assessment can be used to request prior
				authorization for services. The initial (provisional) plan of care for the
				beneficiary is to be signed and dated by the professional who conducted the
				Addiction Assessment. However, a comprehensive treatment plan must be developed
				for each beneficiary (Treatment Planning - New Beneficiary - T1007) within 14
				days of initial contact. The treatment plan becomes effective when the
				psychiatrist or physician signs and dates the treatment plan.
Procedure codes requiring Extension of Benefits
				(Extension of Benefits is only available for U21 beneficiaries):
National Codes
Required Modifier
Service Title
Yearly Maximum
H0001
Addiction Assessment - New Beneficiary
1
H0001
U8
Addiction Assessment - Established Beneficiary
1
T1007
Treatment Planning - New Beneficiary
1
T1007
U8
Treatment Planning - Established Beneficiary
1
H0006
Care Coordination
12
H0047
Multi-Person (Family) Group Counseling
48
H2019
Individual Counseling
48
H0005
Group Counseling
48
T1006
Marital/Family Counseling
48
H2010
Medication Management
12
240.000
REIMBURSEMENT
Reimbursement is based on the lesser of the billed amount or
				the Title XIX (Medicaid) maximum allowable for each procedure.
Reimbursement is contingent upon eligibility of both the
				beneficiary and provider at the time the service is provided and upon accurate
				completeness of the claim filed for the service. The provider is responsible
				for verifying that the beneficiary is eligible for Arkansas Medicaid prior to
				rendering services.
A. Outpatient
			 Services
Fifteen-Minute Units, unless otherwise
				stated
SATS must be billed on a per unit basis, as reflected in a
				daily total, per beneficiary, per SAT 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, 24hour calendar day. Providers may accumulatively
				bill for a single date of service, per beneficiary, per SAT service. Providers
				are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per SAT service, based
				on the established procedure codes. No rounding is allowed.
The sum of the days' time, in minutes, per service will
				determine how many units are allowed to be billed. That number must not be
				exceeded. The total of minutes per service must be compared to the following
				grid, which determines the number of units allowed.
One (1) unit =
8 - 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.
NOTE: For services provided by a paraprofessional (PP),
				the accumulated time for the SAT service, per date of service, is one total,
				regardless of the number of paraprofessionals seeing the beneficiary on that
				day. For example, two (2) paraprofessionals see the same beneficiary on the
				same date of service and provide Care Coordination. The first PP spends a total
				of 10 minutes. Later in the day, another paraprofessional provides Care
				Coordination to the same beneficiary and spends a total of 15 minutes. A total
				of 25 minutes of Care Coordination was provided, which equals (two) 2 allowable
				units of service. Only one PP may be shown on the claim as the performing
				provider.
241.000
Rate Appeal Process
A provider may request reconsideration of a Program decision
				affecting reimbursement by writing to the Assistant Director, Division of
				Medical Services (DMS).
A. The Program
			 must receive the request within 20 calendar days of the latest of the following
			 events:
1. The implementation date of the new
			 or revised policy or
2. The
			 effective date of the new or revised billing or coding instructions
			 or
3. The date of official provider
			 notification of:
a. New or revised policy or
b. New or revised billing or coding
			 instructions
B. The Assistant Director, DMS, will review
			 the request and will arrange a Program/Provider conference if needed or if the
			 provider so requests.
1. The Assistant
			 Director will advise the provider of the Program decision on the matter within
			 20 calendar days following receipt of the request.
2. If there is a Program/Provider conference,
			 the Assistant Director will notify the provider within 20 calendar days
			 following the date of that conference.
C. If the decision of the Assistant Director,
			 DMS, is unsatisfactory to the provider, the provider may then appeal the
			 question to a standing Rate Review Panel established by the Director of the
			 DMS.
1. A member of DHS management staff will
			 chair the Rate Review Panel, which will include a member of the DMS and a
			 representative of the medical professional community.
2. The written request for review by the Rate
			 Review Panel must be postmarked within 15 calendar days following the date of
			 notification of the initial decision by the Assistant Director, DMS.
3. The Rate Review Panel will meet within 15
			 calendar days following receipt of the appeal request. The panel will submit
			 its recommendation to the Director of the DMS.
250.000
BILLING
			 PROCEDURES
251.000
Introduction to Billing
Substance Abuse Treatment Services (SATS) providers use the
				CMS-1500 form to bill the Arkansas Medicaid Program on paper for services
				provided to eligible Medicaid recipients. Each claim may contain charges for
				only one beneficiary. View a CMS-1500 sample form.