Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-143 - Mental health services utilization criteria; definitions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The
				following words and terms when used in this section shall have the following
				meanings unless the context indicates otherwise:
"Certified prescreener" means an employee of either the local
				  community services board or behavioral health authority, or its designee, who
				  is skilled in the assessment and treatment of mental illness and who has
				  completed a certification program approved by DBHDS.
"Certified prescreener assessment" means an assessment for
				  crisis intervention and crisis stabilization completed by a certified
				  prescreener that meets the elements of a comprehensive needs assessment.
"Comprehensive needs assessment" means the same as defined in
				  12VAC30-50-130
				  and also includes individuals who are older than 21 years of age.
"Emergency services" means unscheduled and sometimes
				  scheduled crisis intervention, stabilization, acute psychiatric inpatient
				  services, and referral assistance provided over the telephone or face-to-face
				  if indicated, and available 24 hours a day, seven days per week.
"Licensed mental health professional" or "LMHP" means the
				  same as defined in
				  12VAC30-50-130.
"LMHP-resident" or "LMHP-R" means the same as defined in
				  12VAC30-50-130.
"LMHP-resident in psychology" or "LMHP-RP" means the same as
				  defined in
				  12VAC30-50-130.
"LMHP-supervisee in social work," "LMHP-supervisee," or
				  "LMHP-S" means the same as defined in
				  12VAC30-50-130.
"Qualified mental health professional-adult" or "QMHP-A"
				  means the same as defined in
				  12VAC30-50-130.
"Qualified mental health professional-child" or "QMHP-C"
				  means the same as defined in
				  12VAC30-50-130.
"Qualified mental health professional-eligible" or "QMHP-E"
				  means the same as defined in
				  12VAC35-105-20.
"Qualified paraprofessional in mental health" or "QPPMH"
				  means the same as the term is defined in
				  12VAC35-105-20.
B. Utilization reviews shall include
				determinations that providers meet the following requirements:
1. The provider shall meet the federal and
				state requirements for administrative and financial management capacity. The
				provider shall obtain, prior to the delivery of services, and shall maintain
				and update periodically as the Department of Medical Assistance Services (DMAS)
				or its contractor requires, a current provider enrollment agreement for each
				Medicaid service that the provider offers. DMAS shall not reimburse providers
				who do not enter into a provider enrollment agreement for a service prior to
				offering that service.
2. The
				provider shall document and maintain individual case records in accordance with
				state and federal requirements.
3.
				The provider shall ensure eligible individuals have free choice of providers of
				mental health services and other medical care under the Individual Service
				Plan.
4. Providers shall comply
				with DMAS marketing requirements as set out in
				12VAC30-130-2000.
				Providers that DMAS determines have violated these marketing requirements shall
				be terminated as a Medicaid provider pursuant to
				12VAC30-130-2000
				E. Providers whose contracts are terminated shall be afforded the right of
				appeal pursuant to the Administrative Process Act (§ 2.2-4000 et seq. of
				the Code of Virginia).
5. If an
				individual receiving community mental health rehabilitative services is also
				receiving case management services pursuant to
				12VAC30-50-420
				or
				12VAC30-50-430,
				the provider shall collaborate with the case manager by notifying the case
				manager of the provision of community mental health rehabilitative services and
				sending monthly updates on the individual's treatment status. A discharge
				summary shall be sent to the care coordinator/case manager within 30 calendar
				days of the discontinuation of services. Service providers and case managers
				who are using the same electronic health record for the individual shall meet
				requirements for delivery of the notification, monthly updates, and discharge
				summary upon entry of this documentation into the electronic health
				record.
6. The provider shall
				determine who the primary care provider is and inform him of the individual's
				receipt of community mental health rehabilitative services. The documentation
				shall include who was contacted, when the contact occurred, and what
				information was transmitted.
7.
				Prior to admission, an appropriate comprehensive needs assessment shall be
				conducted by the licensed mental health professional (LMHP), LMHP-S, LMHP-R, or
				LMHP-RP. The comprehensive needs assessment shall include documented history of
				the severity, intensity, and duration of mental health care problems and
				issues. all of the following elements:
(i)
				the presenting issue or reason for referral;
(ii) mental health history or history of
				hospitalizations;
(iii) previous
				interventions by providers and timeframes and response to treatment;
(iv) medical profile;
(v) developmental history including history
				of abuse, if appropriate;
(vi)
				educational or vocational status;
(vii) current living situation and family
				history and relationships;
(viii)
				legal status,
(ix) drug and alcohol
				profile;
(x) resources and
				strengths;
(xi) mental status exam
				and profile;
(xii) diagnosis;
(xiii) professional summary and
				clinical formulation;
(xiv)
				recommended care and treatment goals; and
(xv) the dated signature of the LMHP,
				LMHP-supervisee, LMHP-resident, or LMHP-RP.
a. A single comprehensive needs assessment
				shall be used to document the medical necessity for one or more community
				mental health rehabilitative service provided by the same DBHDS licensed
				agency.
b. The comprehensive needs
				assessment shall be: completed face to face and signed by the LMHP, LMHP-R,
				LMHP-RP, or LMHP-S; include all required elements as defined in
				12VAC30-50-130;
				describe how each recommended community mental health rehabilitative service is
				medically necessary; and be reviewed and updated at a minimum of annually or as
				the individual's needs change.
c.
				The comprehensive needs assessment shall be reviewed and updated by an LMHP,
				LMHP-R, LMHP-RP, or LMHP-S within 31 days if there is a clinical indication
				based on the medical, psychiatric, or behavioral symptoms of the
				individual.
d. An LMHP, LMHP-R,
				LMHP-RP, or LMHP-S shall conduct an annual face to face review and update of
				the comprehensive needs assessment that includes: a review of the comprehensive
				needs assessment; any necessary updates to the 15 required elements of the
				comprehensive needs assessment to reflect the individual's current level of
				functioning; an updated description of how the individual meets medical
				necessity criteria for all recommended services; and a contemporaneously dated
				signature of the LMHP, LMHP-R, LMHP-RP, or LMHP-S.
e. The comprehensive needs assessment is
				outdated if any of the following occurs: an LMHP, LMHP-R, LMHP-RP, or LMHP-S
				has not completed the annual review and update; within the past 31 calendar
				days, the provider has not provided a community mental health rehabilitative
				service or a case management activity (as defined in
				12VAC30-50-420
				or
				12VAC30-50-430)
				as recommended by the comprehensive needs assessment, or, within the past 31
				days, the comprehensive needs assessment has not been updated to reflect a
				change in the individual's current level of functioning.
f. If the comprehensive needs assessment is
				outdated, a new comprehensive needs assessment is required prior to resuming a
				community mental health rehabilitative service that lapsed for more than 31
				calendar days. If the comprehensive needs update is not outdated, it must, at a
				minimum, be updated to document the medical necessity for a community mental
				health rehabilitative service that lapsed for more than 31 calendar
				days.
g. Providers shall only bill
				under the community mental health rehabilitative service assessment codes for
				the initial comprehensive needs assessment and for comprehensive needs
				assessments that replace an outdated assessment. Providers of multiple
				community mental health rehabilitative services shall only bill one community
				mental health rehabilitative service assessment code per individual.
h. Claims for services that are based upon
				comprehensive needs assessments that are incomplete, outdated, or missing shall
				not be reimbursed.
i. For crisis
				intervention and crisis stabilization services, a certified prescreener
				assessment may be used in place of the comprehensive needs
				assessment.
8.
				The provider shall include the individual and the family/caregiver, as may be
				appropriate, in the development of the ISP. To the extent that the individual's
				condition requires assistance for participation, assistance shall be provided.
				The ISP shall be updated annually or as the needs and progress of the
				individual changes. An ISP that is not updated either annually or as the
				treatment interventions based on the needs and progress of the individual
				change shall be considered outdated. An ISP that does not include all required
				elements specified in
				12VAC30-50-226
				shall be considered incomplete. Claims for services that are based upon ISPs
				that are incomplete, outdated, or missing shall not be reimbursed. All ISPs
				shall be completed, signed, and contemporaneously dated by the appropriate
				professional for the service, who is preparing the ISP within a maximum of 30
				days of the date of the completed assessment unless otherwise specified. A
				youth's ISP shall also be signed by the parent or legal guardian and the adult
				individual shall sign his own. If the individual is unwilling to sign the ISP,
				then the service provider shall document the clinical or other reasons why the
				individual was not able or willing to sign the ISP. Signatures shall be
				obtained unless there is a clinical reason that renders the individual unable
				to sign the ISP.
a. Every three months, the
				appropriate professional for the service shall review the ISP, modify the ISP
				as appropriate, and update the ISP, and all of these activities shall occur
				with the individual in a manner in which the individual may participate in the
				process. The ISP shall be rewritten at least annually.
b. The goals, objectives, and strategies of
				the ISP shall be updated to reflect any change or changes in the individual's
				progress and treatment needs as well as any newly-identified
				problems.
c. Documentation of ISP
				review shall be added to the individual's medical record no later than 15 days
				from the calendar date of the review as evidenced by the dated signatures of
				the appropriate professional for the service and the individual.
9. Progress notes shall include,
				at a minimum, the name of the service rendered, the date of the service
				rendered, the signature and credentials of the person who rendered the service,
				the setting in which the service was rendered, and the amount of time or units
				or hours required to deliver the service. The content of each progress note
				shall corroborate the units or hours billed. Progress notes shall be documented
				for each service that is billed.
10. Services described in this section shall
				be rendered consistent with the definitions, service limits, and requirements
				described in this section and in
				12VAC30-50-226.