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 317:30-5-241.6 - Behavioral health targeted case management

Current through Vol. 41, No. 20, July 1, 2024
Payment is made for behavioral health targeted case
					 management services as set forth in this Section. The limitations set forth in
					 this Section do not apply to case management provided in programs and service
					 delivery models which are not reimbursed for case management on a
					 fee-for-service basis.
(1)
Description of behavioral health case management services.
Behavioral health case management services are provided to assist eligible
				  individuals in gaining access to needed medical, social, educational and other
				  services essential to meeting basic human needs. Services under behavioral
				  health targeted case management are not comparable in amount, duration and
				  scope. The target groups for behavioral health case management services are
				  persons under age twenty-one (21) who are in imminent risk of out-of-home
				  placement for psychiatric or substance abuse reasons or are in out-of-home
				  placement due to psychiatric or substance abuse reasons, and chronically and/or
				  severely mentally ill adults who are institutionalized or are at risk of
				  institutionalization. All behavioral health case management services will be
				  authorized based on established medical necessity criteria.
(A) The behavioral health case manager
				  provides assessment of case management needs, development of a case management
				  care plan, referral, linkage, monitoring and advocacy on behalf of the member
				  to gain access to appropriate community resources. The behavioral health case
				  manager must monitor the progress in gaining access to services and continued
				  appropriate utilization of necessary community resources. Behavioral case
				  management is designed to promote recovery, maintain community tenure, and to
				  assist individuals in accessing services for themselves following the case
				  management guidelines established by ODMHSAS. In order to be compensable, the
				  service must be performed utilizing the Strengths Based model of case
				  management. This model of case management assists individuals in identifying
				  and securing the range of resources, both environmental and personal, needed to
				  live in a normally interdependent way in the community. The focus for the
				  helping process is on strengths, interests, abilities, knowledge and capacities
				  of each person, not on their diagnosis, weakness or deficits. The relationship
				  between the service member and the behavioral health case manager is
				  characterized by mutuality, collaboration, and partnership. Assistive
				  activities are designed to occur primarily in the community, but may take place
				  in the behavioral health case manager's office, if more appropriate.
(B) The provider will coordinate transition
				  services with the member and family (if applicable) by phone or face to face,
				  to identify immediate needs for return to home/community no more than
				  seventy-two (72) hours after notification that the member/family requests case
				  management services. For members discharging from a higher level of care than
				  outpatient, the higher level of care facility is responsible for scheduling an
				  appointment with a case management agency for transition and post discharge
				  services. The case manager will make contact with the member and family (if
				  applicable) for transition from the higher level of care other than outpatient
				  back to the community, within seventy-two (72) hours of discharge, and then
				  conduct a follow-up appointment/contact within seven (7) days. The case manager
				  will provide linkage/referral to physicians/medication services, psychotherapy
				  services, rehabilitation and/or support services as described in the case
				  management service plan.
(C) Case
				  managers may also provide crisis diversion (unanticipated, unscheduled
				  situation requiring supportive assistance, face to face or telephone, to
				  resolve immediate problems before they become overwhelming and severely impair
				  the individual's ability to function or maintain in the community) to assist
				  member(s) from progression to a higher level of care. During the follow-up
				  phase of these referrals or links, the behavioral health case manager will
				  provide aggressive outreach if appointments or contacts are missed within two
				  (2) business days of the missed appointments. Community/home based case
				  management to assess the needs for services will be scheduled as reflected in
				  the case management service plan, but not less than one (1) time per month. The
				  member/parent/guardian has the right to refuse behavioral health case
				  management and cannot be restricted from other services because of a refusal of
				  behavioral health case management services.
(D) An eligible member/parent/guardian will
				  not be restricted and will have the freedom to choose a behavioral health case
				  management provider as well as providers of other medical care.
(E) In order to ensure that behavioral health
				  case management services appropriately meet the needs of the member and family
				  and are not duplicated, behavioral health case management activities will be
				  provided in accordance with an individualized plan of care.
(F) The individual plan of care must include
				  general goals and objectives pertinent to the overall recovery of the member's
				  (and family, if applicable) needs. Progress notes must relate to the individual
				  plan of care and describe the specific activities to be performed. The
				  individual plan of care must be developed with participation by, as well as,
				  reviewed and signed by the member, the parent or guardian [if the member is
				  under eighteen (18)], the behavioral health case manager, and an LBHP or
				  licensure candidate as defined in OAC
				  317:30-5-240.3(a) and
				  (b).
(G) SoonerCare reimbursable behavioral health
				  case management services include the following:
(i) Gathering necessary psychological,
				  educational, medical, and social information for the purpose of individual plan
				  of care development.
(ii)
				  Face-to-face meetings with the member and/or the parent/guardian/family member
				  for the implementation of activities delineated in the individual plan of care.
(iii) Face-to-face meetings with
				  treatment or service providers, necessary for the implementation of activities
				  delineated in the individual plan of care.
(iv) Supportive activities such as
				  non-face-to-face communication with the member and/or parent/guardian/family
				  member.
(v) Non face-to-face
				  communication with treatment or service providers necessary for the
				  implementation of activities delineated in the individual plan of care.
(vi) Monitoring of the individual
				  plan of care to reassess goals and objectives and assess progress and or
				  barriers to progress.
(vii) Crisis
				  diversion (unanticipated, unscheduled situation requiring supportive
				  assistance, face to face or telephone, to resolve immediate problems before
				  they become overwhelming and severely impair the individual's ability to
				  function or maintain in the community) to assist member(s) from progression to
				  a higher level of care.
(viii)
				  Behavioral health targeted case management is available to individuals
				  transitioning from institutions to the community [except individuals who are
				  inmates of public institutions]. Individuals are considered to be transitioning
				  to the community during the last thirty (30) consecutive days of a covered
				  institutional stay. This time is to distinguish case management services that
				  are not within the scope of the institution's discharge planning activities
				  from case management required for transitioning individuals with complex,
				  chronic, medical needs to the community. Transition services provided while the
				  individual is in the institution are to be claimed as delivered on the day of
				  discharge from the institution.