Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 21 - OUTPATIENT BEHAVIORAL HEALTH AGENCY SERVICES › Section 317:30-5-241.3 - Behavioral Health Rehabilitation (BHR) services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Definition.
Behavioral
				  Health Rehabilitation (BHR) services are goal oriented outpatient interventions
				  that target the maximum reduction of mental and/or behavioral health
				  impairments and strive to restore the members to their best possible mental
				  and/or behavioral health functioning. BHR services must be coordinated in a
				  manner that is in the best interest of the member and may be provided in a
				  variety of community and/or professional settings that protect and assure
				  confidentiality. For purposes of this Section, BHR includes Psychosocial
				  Rehabilitation, Outpatient Substance Abuse Rehabilitation, and Medication
				  Training and Support.
(b)
Psychosocial Rehabilitation (PSR).
(1)
Definition.
PSR services are
				  face-to-face Behavioral Health Rehabilitation services which are necessary to
				  improve the member's ability to function in the community. They are performed
				  to improve the skills and abilities of members to live interdependently in the
				  community, improve self-care and social skills, and promote lifestyle change
				  and recovery practices. Rehabilitation services may be provided individually or
				  in group sessions, and they take the format of curriculum based education and
				  skills training.
(2)
Clinical
				  restrictions.
This service is generally performed with only the members
				  and the qualified provider, but may include a member and the member's
				  family/support system when providing educational services from a curriculum
				  that focuses on the member's diagnosis, symptom management, and recovery. A
				  member who at the time of service is not able to cognitively benefit from the
				  treatment due to active hallucinations, substance abuse, or other impairments
				  is not suitable for this service. Family involvement is allowed for support of
				  the member and education regarding his/her recovery, but does not constitute
				  family therapy, which requires a licensed provider.
(3)
Qualified practitioners.
A
				  Certified Behavioral Health Case Manager II (CM II), CADC, LBHP , or Licensure
				  Candidate may perform PSR, following development of a service plan and
				  treatment curriculum approved by an LBHP or Licensure Candidate. The CM II and
				  CADC must have immediate access to a LBHP who can provide clinical oversight
				  and collaborate with the qualified PSR provider in the provision of services. A
				  minimum of one monthly face-to-face consultation with a LBHP is required for
				  PSR providers . In addition, a minimum of one face-to-face consultation per
				  week with a LBHP or Licensure Candidateis required for PSR providers regularly
				  rendering services away from the outpatient behavioral health agency
				  site.
(4)
Group sizes.
The maximum staffing ratio is fourteen members for each qualified provider for
				  adults and eight to one for children under the age of eighteen.
(5)
Limitations.
(A)
Transportation.
Travel time
				  to and from PSR treatment is not compensable. Group PSR services do not qualify
				  for the OHCA transportation program, but OHCA will arrange for transportation
				  for those who require specialized transportation equipment.
(B)
Time.
Breaks, lunchtime and
				  times when the member is unable or unwilling to participate are not compensable
				  and must be deducted from the overall billed time.
(C)
Location.
In order to
				  develop and improve the member's community and interpersonal functioning and
				  self care abilities, PSR services may take place in settings away from the
				  outpatient behavioral health agency site as long as the setting protects and
				  assures confidentiality. When this occurs, the qualified provider must be
				  present and interacting, teaching, or supporting the defined learning
				  objectives of the member for the entire claimed time.
(D)
Eligibility for PSR
				  services.
All PSR services require prior authorization and must meet
				  established medical necessity criteria.
(i)
Adults.
PSR services for adults are limited to members who have a
				  history of psychiatric hospitalization or admissions to crisis centers, have
				  been determined disabled by the SSA for mental health reasons, are residing in
				  residential care facilities or are receiving services through a specialty court
				  program.
(ii)
Children.
PSR services for children are limited to members who
				  have a history of psychiatric hospitalization or admissions to crisis centers;
				  have been determined disabled by the SSA for mental health reasons; have a
				  current Individual Education Plan (IEP) or 504 Plan for emotional disturbance;
				  or have been evaluated by a school psychologist, licensed psychologist or
				  psychiatrist and determined to be "at risk" as outlined in the Prior
				  Authorization Manual.
(iii) The
				  following members are not eligible for PSR services:
(I) Residents of ICF/IID facilities, unless
				  authorized by OHCA or its designated agent;
(II) children under age 6, unless a prior
				  authorization for children ages 4 and 5 has been granted by OHCA or its
				  designated agent based on the criteria in (5)(D)(ii) above as well as a finding
				  of medical necessity;
(III)
				  children receiving RBMS in a group home or therapeutic foster home, unless
				  authorized by OHCA or its designated agent;
(IV) inmates of public
				  institutions;
(V) members residing
				  in inpatient hospitals or IMDs; and
(VI) members residing in nursing
				  facilities.
(E)
Billing limits.
PSR services
				  are time-limited services designed to be provided over the briefest and most
				  effective period possible and as adjunct (enhancing) interventions to
				  compliment more intensive behavioral health therapies. Service limits are based
				  on the member's needs according to the CAR or other approved tool, the
				  requested placement based on the level of functioning rating, medical
				  necessity, and best practice. Service limitations are designed to help prevent
				  rehabilitation diminishing return by remaining within reasonable age and
				  developmentally appropriate daily limits. PSR services authorized under this
				  Section are separate and distinct from, but should not duplicate the structured
				  services required for children residing in group home or therapeutic foster
				  care settings, or receiving services in Day Treatment or Partial
				  Hospitalization Programs. Children under an ODMHSAS Systems of Care program and
				  adults residing in residential care facilities may be prior authorized
				  additional units as part of an intensive transition period. PSR is billed in
				  unit increments of 15 minutes with the following limits:
(i)
Group PSR.
The maximum is 24
				  units per day for adults and 16 units per day for children.
(ii)
Individual PSR.
The maximum
				  is six units per day.
(iii)
Per-Member service levels and limits.
Unless otherwise specified,
				  group and/or individual PSR services provided in combination may not exceed the
				  monthly limits established in the individual's prior authorization. Limits on
				  PSR services are established based on the level for which the member has been
				  approved.
(iv)
EPSDT.
Pursuant to OAC
				  317:30-3-65
				  et seq., billing limits may be exceeded or may not apply if documentation
				  demonstrates that the requested services are medically necessary and are needed
				  to correct or ameliorate defects, physical or behavioral illnesses or
				  conditions discovered through a screening tool approved by OHCA or its
				  designated agent. The OHCA has produced forms for documenting an EPSDT child
				  health checkup screening which the provider can access on the OHCA
				  website.
(F)
Progress Notes.
In accordance with OAC
				  317:30-5-241.1,
				  the behavioral health service plan developed by the LBHP or Licensure Candidate
				  must include the member's strengths, functional assets, weaknesses or
				  liabilities, treatment goals, objectives and methodologies that are specific
				  and time-limited, and defines the services to be performed by the practitioners
				  and others who comprise the treatment team. When PSR services are prescribed,
				  the plan must address objectives that are specific, attainable, realistic, and
				  time-limited. The plan must include the appropriate treatment coordination to
				  achieve the maximum reduction of the mental and/or behavioral health disability
				  and to restore the member to their best possible functional level. Progress
				  notes for PSR day programs must be documented in accordance with the
				  requirements found in
				  317:30-5-248(5).
				  Progress notes for all other Behavioral Health Rehabilitation services must be
				  documented in accordance with the requirements found in
				  317:30-5-248(3).
(G)
Additional documentation
				  requirements.
(i) a list/log/sign in
				  sheet of participants for each Group rehabilitative session and facilitating
				  qualified provider must be maintained; and
(ii) Documentation of ongoing consultation
				  and/or collaboration with an LBHP or Licensure Candidate related to the
				  provision of PSR services.
(H)
Non-Covered Services.
The
				  following services are not considered BHR and are not reimbursable:
(i) Room and board;
(ii) educational costs;
(iii) supported employment; and
(iv) respite.