Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part XX - Addiction and Recovery Treatment Services › Section 12VAC30-130-5210 - Peer support services and family support partners: limitations and exclusions to service delivery

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
				  approved service authorization submitted by the enrolled provider shall be
				  required prior to service delivery in order for reimbursement to occur. To
				  obtain service authorization, all provider information supplied to the
				  Department of Medical Assistance Services or its contractor shall be fully
				  substantiated throughout the individual's record.
B. Service shall be initiated within 30
				  calendar days of the documented recommendation. The recommendation shall be
				  valid for no longer than 30 calendar days.
C. Services rendered in a group setting shall
				  have a ratio of no more than 10 individuals to one PRS, and progress notes
				  shall be included in each individual's record.
D. General support groups that are made
				  available to the public to promote education and global advocacy do not qualify
				  as peer support services or family support partners.
E. Noncovered activities include
				  transportation, recordkeeping or documentation activities (including progress
				  notes, tracking hours and billing, and other administrative paperwork),
				  services performed by volunteers, household tasks, chores, grocery shopping,
				  on-the-job training, case management, outreach to potential clients, and room
				  and board.
F. A unit of service
				  shall be defined as 15 minutes. Peer support services and family support
				  partners shall be limited to four hours per day (up to 16 units per calendar
				  day) and 900 hours per calendar year. Service delivery limits may be exceeded
				  based upon documented medical necessity and service authorization
				  approval.
G. If a service
				  recommendation for mental health peer support services or mental health family
				  support partners as set forth in
				  12VAC30-50-130 or
				  12VAC30-50-226 is made in addition
				  to a service recommendation for ARTS peer support services or ARTS family
				  support partners as set forth in 12VAC30-130-5160 through 12VAC30-130-5210, the
				  enrolled provider shall coordinate services to ensure the four-hour daily
				  service limit is not exceeded. No more than a total of four hours of one type
				  of service, or a total of four hours of a combination of service types, up to
				  16 units of total service, shall be provided per calendar day. The enrolled
				  provider cannot bill DMAS separately for (i) mental health peer services
				  (mental health peer support services or mental health family support partners)
				  and (ii) ARTS peer services (peer support services or ARTS family support
				  partners) rendered on the same calendar day unless the mental health peer
				  services and ARTS peer services are rendered at different times. A separate
				  annual service limit of up to 900 hours shall apply to mental health peer
				  support services or mental health family support partners service and ARTS peer
				  support services or ARTS family support partners.
H. The PRS shall document each 15-minute unit
				  in which the individual was actively engaged in peer support services or family
				  support partners. Meals and breaks and other noncovered services listed in this
				  section shall not be included in the reporting of units of service delivered.
				  Should an individual receive other services during the range of documented time
				  in/time out for peer support hours, the absence of or interrupted services must
				  be documented.
I. Service delivery
				  shall be based on the individual's identified needs, established medical
				  necessity criteria, and goals identified in the individual recovery resiliency
				  and wellness plan.
J. Billing shall
				  occur only for services provided with the individual present. Telephone time is
				  supplemental rather than replacement of face-to-face contact and is limited to
				  25% or less of total time per recipient per calendar year. Justification for
				  services rendered with the individual via telephone shall be documented. Any
				  telephone time rendered over the 25% limit will be subject to
				  retraction.
K. Peer support
				  services or family support partners may operate in the same building as other
				  day services; however, there must be a distinct separation between services in
				  staffing, program description, and physical space. Peer support services shall
				  be an ancillary service and shall not impede, interrupt, or interfere with the
				  provision of the primary service setting.
L. Contact shall be made with the individual
				  receiving peer support services or family support partners a minimum of twice
				  each month. At least one of these contacts must be face-to-face and the second
				  may be either face-to-face or telephone contact depending on the individual's
				  support needs and documented preferences.
M. In the absence of the required monthly
				  face-to-face contact and if at least two unsuccessful attempts to make
				  face-to-face contact have been tried and documented, the provider may bill for
				  a maximum of two telephone contacts in that specified month, not to exceed two
				  units. After two consecutive months of unsuccessful attempts to make
				  face-to-face contact, discharge shall occur.
N. Family support partners is not billable
				  for siblings of the targeted individual for whom a need is specified unless
				  there is applicability to the targeted individual or family. The applicability
				  to the targeted individual must be documented.
O. Family support partners services shall not
				  be billed for an individual who resides in a congregate setting in which the
				  caregivers are paid, such as child caring institutions or any other living
				  environment that is not comprised of more permanent caregivers. An exception
				  would be for an individual actively preparing for transition back to a
				  single-family unit, the caregiver is present during the intervention, and the
				  service is directed to supporting the unification or reunification of the
				  individual and his caregiver and takes place in that home and community. The
				  circumstances surrounding the exception shall be documented.
P. Individuals with the following conditions
				  are excluded from family support partners unless there is clearly documented
				  evidence and diagnosis of a substance use disorder or mental health disorder
				  overlaying the diagnosis: developmental disability including intellectual
				  disabilities, organic mental disorder including dementia or Alzheimer's, or
				  traumatic brain injury. There must be documented evidence that the individual
				  is able to participate in the service and benefit from family support
				  partners.
Q. Claims that are not
				  adequately supported by appropriate up-to-date documentation may be subject to
				  recovery of expenditures. Progress notes, as defined in
				  12VAC30-50-130, shall disclose the
				  extent of services provided and corroborate the units billed. Claims not
				  supported by corroborating progress notes shall be subject to recovery of
				  expenditures.
R. The enrolled
				  provider shall be subject to utilization reviews conducted by DMAS or its
				  designated contractor.
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.