Department of Medical Assistance Services Substance Abuse Services Training - PowerPoint PPT Presentation

1 / 91
About This Presentation
Title:

Department of Medical Assistance Services Substance Abuse Services Training

Description:

Reimbursement rates for substance abuse outpatient therapy ... Substance abuse treatment sessions are counted separate from the ... I Substance Use ... – PowerPoint PPT presentation

Number of Views:144
Avg rating:3.0/5.0
Slides: 92
Provided by: Imad4
Category:

less

Transcript and Presenter's Notes

Title: Department of Medical Assistance Services Substance Abuse Services Training


1
Department of Medical Assistance Services
Substance Abuse ServicesTraining
  • September 2007

2
  • This presentation is to facilitate training of
    the subject matter in portions of the Virginia
    Medicaid manuals on Community Mental Health
    Rehabilitative Services and Psychiatric Services.
  • It contains only highlights of those manuals and
    is not meant to be a substitute for or take their
    place.
  • For complete manual copies go to

www.dmas.virginia.gov
3
General Medicaid Provider Participation
Requirements
  • Have administrative and financial management
    capacity to meet federal and state requirements
  • Have ability to maintain business and
    professional documentation
  • Adhere to conditions outlined in the provider
    agreements
  • Notify DMAS of any change in original information
    submitted

4
Participation Requirements contd
  • Maintain records that fully document health care
    provided
  • Retain records for a period of at least 5 years
    (incl. Remits)
  • Furnish access to records and facilities in the
    form and manner requested
  • Use Medicaid designated billing forms
  • Accept as payment in full the amount reimbursed
    by DMAS. Provider must be participating in the
    Medicaid Program at the time the service is
    performed

5
Participation Requirements contd
  • A provider may not bill a client for a covered
    service regardless of whether or not the provider
    received payment from the state
  • Should not attempt to collect from the client or
    family member any amount that exceeds the
    Medicaid allowance or for missed appointments

6
Participation Requirements contd
  • Hold all recipient information confidential
  • Be fully compliant with state and federal HIPAA
    confidentiality, use and disclosure requirements

7
Psychiatric Outpatient Substance Abuse Services
8
Provider Qualifications for Outpatient
Psychiatric SA Services
  • An individual licensed by the Virginia
    Department of Health Professions as either a
  • Professional Counselor
  • Clinical Social Worker
  • Psychiatric Clinical Nurse Specialist
  • Psychiatric Nurse Practitioner
  • Marriage And Family Therapist
  • Clinical Psychologist, or
  • Physician
  • Individual who has completed a graduate degree
    and is under the direct personal supervision of a
    licensed provider

9
Provider Qualifications for Outpatient
Psychiatric SA Services
  • In addition to licensure requirements, substance
    abuse treatment providers must also be qualified
    by training and experience in the following areas
    of substance abuse/addiction counseling
  • clinical evaluation
  • treatment planning
  • referral
  • service coordination
  • client and family education
  • documentation professional and ethical
    responsibilities.
  • Liscensed SA treament providers may provide out
    pt SA only.

10
Direct Supervision of Unlicensed Personnel
  • LMHP SUPERVISOR must be
  • Appropriately licensed under state law
  • Supervision meets requirements of individual
    profession
  • Approves and signs Plan of Care
  • Reviews Patients medical history
  • Countersigns Plan of Care updates

11
Supervision of Unlicensed Personnel contd
  • Reviews each progress note
  • Countersigns each progress note on date of
    service indicating note was reviewed
  • Meet regularly (every six sessions)
  • Discuss Plan of Care
  • Review record
  • Note Patients progress
  • Document supervisory meetings

12
Outpatient Psychiatric Services may be provided
in a
  • Practitioners office
  • Mental health clinic
  • In a group home / nursing home
  • In the clients home

13
Criteria for Participation
  • To qualify for outpatient psychiatric /
    substance abuse services recipients must meet
    the following criteria
  • At risk for developing or requires treatment
    for maladaptive coping strategies and
  • Reduction in adaptive and coping mechanisms or
    extreme increase in personal distress and
  • Exhibits dysfunctional symptoms and
  • Requires treatment to sustain behavioral or
    emotional gains or restore functional levels
  • Recipient must meet DSM-IV-TR diagnostic
    criteria for substance abuse or mental health
    disorder. Nicotine or caffeine abuse or
    dependence are not covered. American Society of
    Addiction Medicine (ASAM) criteria will be used
    to determine the appropriate level of treatment.

14
Documentation Required for SA Psychiatric Out
Patient Services
  • Results of a Diagnostic Evaluation done within
    the past year (History)
  • Description of functional limitations.
  • Include full DSM-IV (SA or MH)
  • Medical Evaluation (evidence of coordination with
    the PCP, if applicable, or documentation that it
    is not applicable).

15
Documentation Required contd
  • Plan(s) of Care, signed and dated by the
    provider.
  • Focus of the Plan must
  • Be related to the diagnosis
  • Indicate client-specific goals related to
    symptoms and behaviors
  • Indicate treatment modalities why the modality
    was chosen
  • Indicate estimated length treatment will be
    needed frequency of treatments
  • Include discharge planning
  • Plan of Care must be reviewed every 90 days or
    every sixth session, whichever time frame is
    shorter

16
Documentation Required contd
  • Progress Notes for each session
  • -Describe how the activities of the session
    relate to the client-specific goals,
  • -Document the date, length type of session
  • -Describe the level of participation in treatment
  • -Contain signature credentials of provider
  • A Discharge Summary is required

17
Outpatient Service Limits
  • No more than a total of three billed treatment
    interventions in a seven-day period
  • Individual psychotherapy
  • Group psychotherapy
  • Family psychotherapy

18
Service Limits contd
  • EXCLUSIONS
  • Multiple-family group psychotherapy
  • Hypnotherapy
  • Interpretation of examinations, procedures data
  • Preparations of reports

19
Non-Covered Psychiatric Services
  • Broken appointments
  • Remedial education
  • Day care / respite
  • Occupational therapy
  • Teaching Grooming skills / ADLs
  • Telephone consultations

20
Substance Abuse Services include
  • Assessment and evaluation
  • Outpatient treatment
  • Crisis intervention
  • Case management
  • Intensive outpatient treatment
  • Day treatment
  • Opioid treatment

21
SA Assessment Evaluation and Outpatient Services
  • Assessment and Evaluation (CPT Codes 90801
    90802)
  • Outpatient Individual, Group and Family Therapy
    (CPT Codes 90804-90809, 90812-90815, 90846 -
    90847, 90853 and 90857)
  • Medicaid MCOs will establish their own prior
    authorization (PA) criteria and perform
    authorizations
  • DMAS will conduct PA for fee-for-service (FFS)

22
Reimbursement for Outpatient SA Treatment
  • Rates are the same as corresponding Mental Health
    Outpatient Therapy Services
  • CPT code must have the modifier HF associated
    with it
  • Reimbursement rates for substance abuse
    outpatient therapy (individual, family, and
    group) services for fee-for-service participants
    may be reviewed at www.dmas.virginia.gov/pr-fee_fi
    les.htm
  • Also see included handout

23
SA Outpatient Therapy Limitations
  • Individual, family, and group outpatient
    therapies limited to twenty-six sessions per year
  • The SA 26 sessions is separate from the MH
    outpatient sessions
  • Providers can render SA outpatient therapy
    services, up to 26 sessions without prior
    authorization in the first year of treatment. An
    additional twenty-six sessions may be prior
    authorized in the first year only
  • After first treatment year, up to 26 sessions
    available with prior authorization
  • If a child under 21 years of age requires
    services beyond these limits, coverage may be
    available through the Early and Periodic
    Screening, Diagnosis, and Treatment program

24
Providers of SA Services
  • Currently enrolled independent professional
    providers of outpatient (individual, family, and
    group) services who meet the provider
    qualifications for substance abuse services not
    need to re-enroll with Medicaid
  • Currently enrolled community rehabilitative
    substance abuse service providers who meet
    qualifications criteria for substance abuse
    services do not need to re-enroll with Medicaid

25
New Providers of SA Services
  • DMAS is enrolling new licensed substance abuse
    treatment practitioners as Medicaid-enrolled
    independent providers
  • Mental health clinics will also be able to bill
    for services provided by licensed substance abuse
    treatment practitioners, if clinic has a valid
    Medicaid provider agreement

26
Provider Enrollment Unit Address
  • For enrollment, agreements, change of address,
  • and enrollment questions contact
  • First Health VMAP Provider Enrollment Unit
  • P.O. Box 26803
  • Richmond, Va. 23261
  • Helpline -- 804-270-5105 Richmond
  • Toll free -- 888-829-5373
  • Fax -- 804-270-7027

27
  • Substance Abuse Outpatient Treatment Prior
    Authorization

28
SA Outpatient Therapy PA
  • Substance abuse treatment sessions are counted
    separate from the psychiatric services.
  • Providers are encouraged to integrate treatment
    for clients with co-occurring psychiatric SA
    conditions
  • May have concurrent authorizations for SA
    treatment and psychiatric services.

29
SA Outpatient Therapy PA contd
  • Up to 26 sessions without prior authorization in
    the first year of treatment
  • An additional twenty-six sessions may be prior
    authorized in the first year only
  • After the first treatment year, up to 26 sessions
    are available with prior authorization
  • If a child under 21 requires services beyond
    these limits, coverage through Early and Periodic
    Screening, Diagnosis, and Treatment (EPSDT)
    program may be requested

30
SA Outpatient Therapy PA contd
  • SA Treatment Practitioners are only eligible to
    provide CPT codes with HF modifiers, excluding
    the evaluation and management codes.
  • CPT codes 90804 through 90815, 90846, 90847,
    90853 and 90857 are available for Substance Abuse
    services, with the HF modifier.
  • CPT codes 90805, 90807, 90809, 90811, 90813, and
    90815 include medical evaluation and management
    and only psychiatrists, psychiatric nurse
    practitioners and psychiatric clinical nurse
    specialists may bill these codes when
    appropriate.
  • Claims for services that exceed the sessions
    available to the individual without authorization
    will be denied.

31
SA Outpatient Therapy PA contd
  • Prior Authorization Request Process
  • Ask client if they have seen another provider.
  • To check if authorization is required for
    additional SA services call the Medicaid HELPLINE
    at 1-800-552-8627
  • -- Have the clients Medicaid number
  • -- Ask the HELPLINE for the record of
    utilization of psychiatric services
  • -- Ask the HELPLINE whether any other
    provider is indicated on the file and the last
    date of service for which a claim was paid.
  • --To request prior authorization for SA
    services, submit a fax request to DMAS at
    1-866-364-3526. The fax form (363-A) is available
    in electronically-fillable format on the DMAS
    website at
  • www.dmas.virginia.gov

32
SA Outpatient Therapy PA contd
  • Initial Review- new provider to recipient
  • Clinical information needed from provider for PA
  • Axis I Substance Use Disorder Diagnosis
  • If dual diagnosis of MH SA, the focus of
    treatment must be provided for the PA request. A
    separate PA request is required for SA and MH if
    the plan is to provide these services
    intermittently.
  • -- Describe any potential safety risk within the
    past month
  • -- Describe any impairment in functioning
    within the past month
  • -- Confirm ASAM Level of Care Assessment
    completed, and recommendation
  • -- Confirm recipients ability to comply
    with treatment
  • -- Confirm modality (i.e., individual,
    family, group)
  • -- Frequency and duration of treatment
  • -- Confirm Substance Abuse evaluation/plan
    of care completed, with dated signature of
    qualified provider

33
SA Outpatient Therapy PA contd
  • Concurrent Review (same provider)
  • Clinical information needed from provider for PA
  • Axis I Substance Use Disorder Diagnosis
  • All of the following should be available in the
    required Plan of Care and/or 90-Day Update
    required by DMAS
  • --Confirm psychosocial assessment completed
  • -- Confirm psychiatric and/or medication
    evaluation and/or toxicology screen or
    breathalyzer completed if needed
  • -- Symptoms and behaviors within the past 30
    days that support the need for continued
    treatment
  • -- Services and compliance within the past
    30 days
  • -- Functioning within the past 30 days
  • -- Progress, or if little or none, explain
    how this is being addressed

34
SA Outpatient Therapy PA contd
  • ADULT Discharge Criteria
  • No active cravings for substances that impact
    Activities of Daily Living (ADLs)
  • No current preoccupations with getting high or
    past drug experiences that impact ADLs
  • Minimal or manageable guilt, remorse, and/or
    shame
  • No drug seeking behaviors
  • No drug glorification that impact ADLs
  • Has attended 80 or more of scheduled sessions
    of therapy sessions in the past month
  • Has no uncontrolled abusive or addictive
    behaviors at home, work or in peer interactions
  • Has had no positive drug screens or positive
    breathalyzer tests in the last 6 months
  • Has family/ peer connections that support
    sobriety.
  • Client may be continued in a relapse prevention
    phase for an additional 6 months, to include
  • One session of individual or group therapy
    every 2 weeks, or less frequently
  • Random urine or breathalyzer monitoring at
    least twice in 6 months
  • Encourage attendance at 12-step programs

35
SA Outpatient Therapy PA contd
  • ADOLESCENT Discharge Criteria
  • No active cravings for substances that impact
    Activities of Daily Living (ADLs)
  • No current preoccupations with getting high or
    past drug experiences that impact ADLs
  • Minimal or manageable guilt, remorse, and/or
    shame
  • No drug seeking behaviors
  • No reckless or acting out behaviors directly
    related to substance use/abuse
  • Has attended 80 or more of the scheduled therapy
    sessions in the past month
  • Has no uncontrolled abusive or addictive
    behaviors at school or in social life
  • Has had no positive drug screens or positive
    breathalyzer tests in the last 6 months
  • Has family/peer connections that support sobriety
  • Client may be continued in a relapse prevention
    phase for an additional 6 months, to include
  • One session of individual or group therapy every
    2 weeks, or less frequently
  • Random urine or breathalyzer monitoring at least
    twice in 6 months
  • Encourage attendance at 12-step programs

36
  • Community Substance Abuse Rehabilitative Services

37
Community SA Rehabilitative Services Overview
38
Community SA Rehabilitative Services Overview
(Cont.)
Note Use DMAS limits and unit definitions as
opposed to the national HCPCS codes.
39
Community SA Rehabilitative Services Overview
(Cont.)
40
Qualified Substance Abuse Professional (QSAP)
  • A. Individual with completed Masters level
    training in psychology, social work, counseling,
    or rehabilitation who also is either
  • (i) certified as substance abuse counselor by the
    Virginia Board of Counseling, or
  • (ii) certified addictions counselor by the
    Substance Abuse Certification Alliance of
    Virginia, or
  • (iii) holds any certification from the National
    Association of Alcoholism and Drug Abuse
    Counselors, or the International Certification
    and Reciprocity Consortium/Alcohol and Other Drug
    Abuse, Inc (IC RC) or
  • B. Individual licensed as either a professional
    counselor, clinical social worker, registered
    nurse, psychiatric clinical nurse specialist, a
    psychiatric nurse practitioner, marriage and
    family therapist, clinical psychologist, or
    physician who is qualified by training
    experience in addiction counseling or
  • C. Individual licensed as a substance abuse
    treatment practitioner by the Virginia Board of
    Counseling or
  • D. Individual certified as either a clinical
    supervisor by the Substance Abuse Certification
    Alliance of Virginia or as a Master Addiction
    Counselor by the National Association of
    Alcoholism and Drug Abuse Counselors or from the
    International Certification and Reciprocity
    Consortium/Alcohol and Other Drug Abuse, Inc (IC
    RC) or
  • E. Individual with completed Masters level
    training in psychology, social work, counseling,
    or rehabilitation and is certified as a Master
    Addiction Counselor by the National Association
    of Alcoholism and Drug Abuse Counselors or from
    the International Certification and Reciprocity
    Consortium/Alcohol and Other Drug Abuse, Inc (IC
    RC) or

41
Qualified Substance Abuse Professional (QSAP)
contd
  • F. Individual with bachelors degree and
    certified as a Substance Abuse Counselor by the
    Board of Counseling or
  • G. Individual with bachelors degree and
    certified as an Addictions Counselor by the
    Substance Abuse Certification Alliance of
    Virginia or
  • H. Individual with bachelors degree and
    certified as a Level II Addiction Counselor by
    the National Association of Alcoholism and Drug
    Abuse Counselors or from the International
    Certification and Reciprocity Consortium/Alcohol
    and Other Drug Abuse, Inc (IC RC)
  • Bachelor level staff with certifications require
    supervision every two weeks by professional
    meeting one of the criteria specified in A
    through E.

42
Paraprofessional Qualifications
  • Paraprofessionals must meet the following
    qualifications
  • An associate's degree in human service at one
    year experience providing direct services to
    persons with a diagnosis of mental illness /
    substance abuse or
  • Associate's or higher degree, in unrelated field
    three years experience providing direct
    services to persons with a diagnosis of mental
    illness / substance abuse or

43
Paraprofessional Qualifications contd
  • Minimum of 90 hours classroom training in
    behavioral health 12 weeks experience under
    direct personal supervision of a QSAP providing
    services or
  • College credits earned towards bachelor's degree
    in a human service field equivalent to
    associate's degree one year's clinical
    experience or
  • Licensure by the Commonwealth as a practical
    nurse with one year of clinical experience
  • Paraprofessionals must participate in clinical
    supervision with a QSAP at least twice a month.
  • Experience may include supervised internships,
    practicums and field experience.

44
Substance Abuse Case Management (H0006)
  • Provider must be licensed by DMHMRSAS as a
    provider of substance abuse case management
    services
  • May bill Medicaid for substance abuse case
    management only when the services are provided by
    professionals who meet the following criteria
  • a. Bachelors degree one year of SA related
    clinical experience providing direct services
  • b. Licensure RN or LPN one year of SA related
    clinical experience

45
Substance Abuse Case Management (H0006)
  • Service Definition
  • SA Case Management assists with accessing needed
    substance abuse, medical, psychiatric, social,
    educational, vocational services other supports
    essential to meeting basic needs
  • If client has co-occurring mental health and SA
    disorders, the case manager should address both
    the MH SA disorders
  • Only one type of case management may be billed at
    one time

46
SA Case ManagementEligibility Criteria
  • Recipient must meet DSM-IV-TR diagnostic criteria
    for Axis I substance-related disorder. Nicotine
    or caffeine abuse or dependence are not covered
  • Must require case management based on an
    appropriate assessment and supporting
    documentation
  • Must be an active client, -- requires regular
    direct or client-related contacts, communication
    or activity

47
SA Case Management Required Activities
  • Initial Assessment
  • ISP fully completed within 30 days of service
    initiation
  • ISP modified as necessary, reviewed every three
    months, and rewritten annually
  • Mandatory monthly CM contact / activity to
    include as needed
  • Linking the individual to services
  • Assisting directly for the purpose of locating,
    developing, or obtaining needed services and
    resources

48
SA Case Management Required Activities contd
  • Coordinating services and treatment planning.
  • Enhancing community integration
  • Making collateral contacts with significant
    others.
  • Monitoring service delivery through contacts with
    service providers as well as periodic site visits
    and home visits.
  • Education and counseling
  • A face-to-face contact must be made at least once
    every 90-day period.

49
SA Case Management Documentation Requirements
  • Documentation that choice of a provider has been
    offered
  • Release forms must be completed for the release
    of any information
  • Initial comprehensive assessment / reassessments
  • ISPs which demonstrates the recipient was
    involved in and sign the plan
  • ISPs from other providers rendering services to
    the recipient are in the record

50
SA Case Management Documentation Requirements
contd
  • Revisions / updates of the ISP whenever the
    amount, type, or frequency of services rendered
    changes
  • Documented quarterly reviews of the ISP to
    determine if service goals / objectives are being
    met
  • Documentation that notes all contacts made by the
    case manager

51
SA Case Management Service Units Limitations
  • The billing unit for case management is 15
    minutes Maximum service limit for substance abuse
    case management services is 52 hours per year.
  • Billing submitted for case management only when
    direct or client-related contacts, activity, or
    communications occur.
  • Reimbursement provided only for active case
    management
  • No other type of case management may be billed
    concurrently with substance abuse case management

52
SA Case Management Service Units Limitations
contd
  • Reimbursement for CM services for individuals in
    an Institution for Mental Disease (IMD) is not
    allowed
  • Discharge planning CM services may be billed
  • -- Three conditions must be met
  • The services may not duplicate the services of
    the institutional discharge planner,
  • Are limited to one month of service, 30 days
    prior to discharge from the facility
  • May be billed for no more than two
    non-consecutive pre-discharge periods in 12
    months

53
Substance Abuse Crisis Intervention (H0050)
  • SA Crisis Intervention service agencys must be
    licensed as a Substance Abuse Outpatient Service
    provider by DMHMRSAS
  • May bill Medicaid for SA Crisis Intervention when
    services are provided by professionals who meet
    the following criteria
  • QSAP
  • Certified Pre-screener,
  • Paraprofessional (safety monitoring only)

54
Substance Abuse Crisis Intervention
  • Service Definition
  • Crisis Intervention services are SA treatment
    interventions available 24/7 to provide
    assistance to individuals experiencing acute
    dysfunction related to substance use which
    requires immediate clinical attention
  • The objectives are
  • To prevent exacerbation of a condition
  • To prevent injury to the recipient or others
    and
  • To provide treatment in the least restrictive
    setting.

55
SA Crisis Intervention Eligibility Criteria
  • SA Crisis Intervention services are provided
    following a marked reduction in the recipients
    psychiatric, adaptive, or behavioral functioning
    or an extreme increase in personal distress
  • If an individual has co-occurring mental health
    and substance use disorders, integrated treatment
    for both disorders is allowed within Substance
    Abuse Crisis Intervention Services

56
SA Crisis Intervention Required Activities
  • QSAP or Certified CSB Pre-screener must complete
    document face-to-face assessment of the crisis
    situation provide short-term counseling provide
    access to further immediate assessment and
    follow-up and link to ongoing care
  • Must be documentation of immediate substance
    abuse treatment
  • Services may be provided outside of the clinic
    and billed if it is clinically or
    programmatically appropriate

57
SA Crisis Intervention Required Activities contd
  • Monitoring F to F support may be provided by a
    QSAP, a certified prescreener, or a
    paraprofessional to ensure the clients safety
  • ISP is not required for newly admitted recipients
  • ISP prepared by a Certified Pre-screener or QSAP
    by the fourth face-to-face
  • If case management is being provided, there must
    be coordination with the case management agency
  • If other clinic services are billed while
    receiving C I services, documentation must
    clearly support separation of services with
    distinct treatment goals

58
SA Crisis Intervention Service Units
Limitations
  • A unit of service is 15 minutes of SA CI. Maximum
    of 720 units can be provided annually.
  • Face-to-face contact with the recipient must
    occur during crisis episode to bill for SA CI
    services.
  • Reimbursement is provided for short-term crisis
    counseling contacts scheduled within 30-day
    period from the time of the first F-to-F crisis
    contact.
  • Staff travel time is excluded from billable time.
  • Medicaid cannot be billed for SA CI services for
    recipient under Emergency Custody Orders or
    Temporary Detention Orders

59
Substance Abuse Intensive Outpatient (H2016)
  • SA IOP service agencys must be licensed as a
    Substance Abuse Outpatient Service provider by
    DMHMRSAS.
  • May bill Medicaid for SA IOP when services are
    provided by professionals who meet the following
    criteria
  • QSAP (Bachelors or Masters)
  • Paraprofessional

60
Substance Abuse Intensive Outpatient
  • Service Definition
  • Intensive outpatient services is provision of
    coordinated, intensive, comprehensive,
    multidisciplinary treatment through a combination
    of diagnostic, medical, psychiatric, and
    psychosocial interventions. Intensive outpatient
    services include assessment, treatment planning,
    counseling, medication monitoring, behavior
    management, and psycho education

61
SA Intensive Outpatient Eligibility Criteria
  • Recipient must meet DSM-IV-TR diagnostic criteria
    for Axis I substance-related disorder. Nicotine
    or caffeine abuse or dependence are not covered.
    American Society of Addiction Medicine (ASAM)
    criteria will be used to determine the
    appropriate level of treatment
  • If individual has co-occurring mental health /
    substance use disorders, integrated treatment for
    both disorders is allowed within SA IOP treatment

62
SA Intensive Outpatient Required Activities
  • Program must operate minimum of two continuous
    hours in a 24-hour period
  • QSAP must perform a F-to-F evaluation /
    diagnostic assessment authorize services prior
    to initiation. If service is longer than 90
    continuous days, QSAP must perform a face-to-face
    evaluation and re-authorize service
  • ISP must be completed by a QSAP within 30 days of
    service initiation
  • Individual, group counseling, family therapy,
    occupational recreational therapy must be
    provided by at least a QSAP
  • QSAP or paraprofessional may provide education
    about the effects of alcohol and other drugs on
    the physical, emotional and social functioning of
    the individual, relapse prevention, occupational
    and recreational activities

63
SA Intensive Outpatient Required Activities
contd
  • QSAP must be onsite when the paraprofessional is
    providing service
  • QSAP must supervise the paraprofessional at least
    twice a month
  • Paraprofessionals who do not meet experience
    requirements may provide services for Medicaid
    reimbursement if they are working directly with a
    qualified paraprofessional on-site supervised
    by a QSAP
  • Progress notes must be completed when services
    are delivered
  • If case management is being provided, there must
    be coordination with the case management agency

64
SA Intensive Outpatient Service Units
Limitations
  • Service is provided to recipients who do not
    require inpatient, residential, or day treatment
    services, but require more than outpatient
    services
  • Individuals must be discharged when other less
    intensive services may achieve stabilization
  • One unit of service is 15 minutes. Reimbursement
    is based on the level of professional providing
    the service
  • Minimum number of service hours per week is 4
    hours with a maximum of 19 hours per week
  • The maximum annual limit is 600 hours
  • Intensive outpatient services may not be provided
    concurrently with day treatment services or
    opioid treatment services
  • Staff travel time is excluded

65
Substance Abuse Day Treatment (H0047)
  • SA Day Treatment agencys must be licensed as a
    provider of Day Treatment service by DMHMRSAS
  • May bill Medicaid for SA IOP when services are
    provided by professionals who meet the following
    criteria
  • QSAP (Bachelors or Masters)
  • Paraprofessional

66
SA Day Treatment
  • Service Definition
  • Day treatment is the provision of coordinated,
    intensive, comprehensive, and multidisciplinary
    treatment through a combination of diagnostic,
    medical, psychiatric, and psychosocial
    interventions. Day Treatment services include
    assessment, treatment planning, counseling,
    medication monitoring, behavior management, and
    psycho education

67
SA Day Treatment Eligibility Criteria
  • Recipient must meet DSM-IV-TR diagnostic criteria
    for Axis I substance-related disorder. Nicotine
    or caffeine abuse or dependence are not covered.
    American Society of Addiction Medicine (ASAM)
    criteria will be used to determine the
    appropriate level of treatment
  • If individual has co-occurring mental health /
    substance use disorders, integrated treatment for
    both disorders is allowed within SA Day Treatment

68
SA Day Treatment Required Activities
  • Program must operate minimum of two continuous
    hours in a 24-hour period
  • QSAP must perform a F-to-F evaluation /
    diagnostic assessment authorize services prior
    to initiation. If service is longer than 90
    continuous days, QSAP must perform a face-to-face
    evaluation and re-authorize services
  • ISP must be completed by a QSAP within 30 days of
    service initiation
  • Individual, group counseling, family therapy,
    occupational recreational therapy must be
    provided by at least a QSAP
  • QSAP or paraprofessional may provide education
    about the effects of alcohol and other drugs on
    the physical, emotional and social functioning of
    the individual, relapse prevention, occupational
    and recreational activities

69
SA Day Treatment Required Activities contd
  • QSAP must be onsite when the paraprofessional is
    providing services
  • QSAP must supervise the paraprofessional at least
    twice a month
  • Paraprofessionals who do not meet experience
    requirements may provide services for Medicaid
    reimbursement if they are working directly with a
    qualified paraprofessional on-site supervised
    by a QSAP
  • Progress notes must be completed when services
    are delivered
  • If case management is being provided, there must
    be coordination with the case management agency

70
SA Day TreatmentService Units Limitations
  • Service is provided to recipients who do not
    require inpatient or residential services
  • Individuals must be discharged when other less
    intensive services may achieve stabilization
  • One unit of service is 15 minutes. Reimbursement
    is based on the level of professional providing
    the service.
  • Minimum number of service hours per week is 20
    hours with a maximum of 30 hours per week.
  • Maximum annual limit is 1,300 hours
  • Staff travel time is excluded

71
Opioid Treatment (H0020)
  • Opioid Treatment agencys must be licensed as a
    provider of Opioid Treatment services by DMHMRSAS
  • May bill Medicaid for Opioid Treatment when
    services are provided by professionals who meet
    the following criteria
  • QSAP (Bachelors or Masters)
  • Paraprofessional

72
Opioid Treatment
  • Service Definition
  • Opioid Treatment services provide an
    intervention strategy that combines substance
    abuse treatment with the administering or
    dispensing of opioid agonist treatment
    medication. An individual-specific,
    physician-ordered dose of medication is
    administered or dispensed either for
    detoxification or maintenance treatment.
  • Treatment is provided in daily sessions

73
Opioid Treatment Eligibility Criteria
  • Recipient must meet DSM-IV-TR diagnostic criteria
    for Axis I substance-related disorder. Nicotine
    or caffeine abuse or dependence are not covered.
    American Society of Addiction Medicine (ASAM)
    criteria will be used to determine the
    appropriate level of treatment
  • If individual has co-occurring mental health /
    substance use disorders, integrated treatment for
    both disorders is allowed within the Opioid
    Treatment

74
Opioid Treatment Required Activities
  • QSAP must perform a F-to-F evaluation /
    diagnostic assessment authorize services prior
    to initiation. If service is longer than 90
    continuous days, QSAP must perform a face-to-face
    evaluation and re-authorize services
  • ISP must be completed by a QSAP within 30 days of
    service initiation
  • Individual, group counseling, family therapy,
    occupational recreational therapy must be
    provided by at least a QSAP
  • QSAP or paraprofessional may provide education
    about the effects of alcohol and other drugs on
    the physical, emotional and social functioning of
    the individual, relapse prevention, occupational
    and recreational activities

75
Opioid Treatment Required Activities contd
  • QSAP must be onsite when the paraprofessional is
    providing services
  • QSAP must supervise the paraprofessional at least
    twice a month
  • Paraprofessionals who do not meet experience
    requirements may provide services for Medicaid
    reimbursement if they are working directly with a
    qualified paraprofessional on-site supervised
    by a QSAP
  • Progress notes must be completed when services
    are delivered
  • If case management is being provided, there must
    be coordination with the case management agency

76
Opioid Treatment Service Units Limitations
  • Individuals must be discharged when other less
    intensive services may achieve stabilization
  • One unit of service is 15 minutes. Reimbursement
    is based on the level of professional providing
    the service.
  • The maximum annual limit is 600 hours.
  • Staff travel time is excluded
  • Providers may submit reimbursement claims for
    opioids which are administered to persons
    receiving Opioid Treatment Services. Providers
    may enroll as a Pharmacy provider
  • Pharmacies would bill as point of sale

77
Utilization Review For Substance Abuse Services
78
  • Federal regulations require that DMAS review and
    evaluate the services provided through the
    Medicaid program

79
Purpose of Utilization Review
  • Ensure clinical necessity and that an
    appropriate provider delivers the services

Ensure the provision of quality health care
Ensure program integrity
80
General UR Facts
  • Reviews will be initiated on a regular basis to
    meet federal requirements or by referrals and
    complaints from agencies or individuals
  • Reviews may be unannounced
  • Review may be based on a random
  • sample from the provider's Medicaid
  • billing
  • A targeted review may be conducted if an
    excessive number of exceptions or problems are
    identified

81
Your UR Site Visit
  • Record Review will include
  • Request to review billing
  • records in a central
  • location
  • The Review may include
  • Observation of service delivery
  • Face-to-face/telephone
  • interviews
  • Review of staff qualifications

82
UR staff check that
  • Services provided meet all requirements defined
    and described in the DMAS Service manual
  • Services billed match documented delivered care
  • Services do not exceed specific service
    limitations

83
The UR Golden Rule
  • Delivered services as documented are consistent
    with the recipients Individual Service Plan,
    submitted invoices and specified service
    limitations

84
UR Problem Areas
  • For All Services
  • Missing or incomplete assessments
  • Assessments completed after service initiation
  • Checklists not corroborated with supporting
    documentation
  • ISPs missing or late
  • ISPs not individualized and specific
  • Missing re-authorizations for services

85
UR Problems contd
  • Documentation not correlating with time / units
    billed or needs on ISP
  • Missing documentation / lack of description of
    billable services
  • Signatures and credentials (qualifications) not
    documented
  • Documentation not completed within appropriate
    timeframe
  • Billing for services beyond specific limitations
  • Documentation not legible

86
Reporting Process
  • After the review, UR staff will conduct an exit
    conference to describe findings and provide
    technical assistance

Written report follows within 2 weeks
Providers may request a reconsideration
87
Overpayments required when
  • Medicaid billed contrary to regulation or statute
  • Provider fails to maintain any record or adequate
    documentation to support the claim
  • Provider bills for an unnecessary service
  • Error found in computing billing amounts

88
Reconsideration of Adverse Actions
  • Process has 3 phases-
  • Written response and reconsideration to
    preliminary findings (30 days to submit
    information)
  • The informal conference (30 days to request
    informal conference)
  • The formal evidentiary hearing
  • (30 days to request formal hearing)

89
Repayment of Identified Overpayments
  • Section 32.1-325.1 of the Code of Virginia,
    mandates that DMAS collect identified
    overpayments
  • Repayment must be made on demand unless a
    repayment schedule is agreed upon by DMAS
  • When a lump sum cash payment is not made,
    interest will be added on the declining balance
    at the statutory rate

90
DMAS Contact Information
  • DMAS SA Phone Line for PA questions
  • 804-371-2645
  • Catherine Hancock
  • Catherine.hancock_at_dmas.virginia.gov
  • 804-225-4272
  • William OBier
  • William.obier_at_dmas.virginia.gov
  • 804-225-4050

91
Thank You!
www.dmas.virginia.gov
Write a Comment
User Comments (0)
About PowerShow.com