Community Mental Health Rehabilitative Services Training

1
Community Mental Health Rehabilitative Services
Training

• Medicaid Eligibility and Billing
• April 2004
• Part I
• www.dmas.virginia.gov

2
Training Objectives

• Recognize Provider requirements for participation
  in the Virginia Medicaid program
• Medicaid eligibility verification options
• Apply accurate billing information to CMS1500
  form
• Identify each of the mental health services
  offered under the Community Mental Health
  Rehabilitative Services manual

3
Training Objectives (contd)

• Information on appropriate service limitations
  when providing the specific service
• Demonstrate knowledge of Medicaid documentation
  requirements

4
Participating Provider

• Appropriately licensed by DMHMRSAS (Chapter II,
  CMHRS)
• Agency or program that meets the standards and
  requirements set forth by DMAS and that has a
  current, signed participation agreement with DMAS

5
Provider Enrollment Unit Address

• For enrollment, agreements, change of address,
  and enrollment questions
• 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

6
Participation Requirements

• Adhere to conditions outlined in the provider
  agreements
• Notify DMAS of any change in original information
  submitted
• Provider must be participating in the Medicaid
  Program at the time the service is performed

7
Participation Requirements

• Ensure freedom of choice to clients in seeking
  medical care from any institution, pharmacy, or
  practitioner qualified to perform the required
  service(s) and participating in the Medicaid
  Program at the time the service was performed
• Ensure the client's freedom to reject medical
  care and treatment

8
Participation Requirements

• Accept as payment in full the amount established
  by DMAS to be the reasonable cost or maximum
  allowable cost
• 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.

9
Participation Requirements

• Be in full compliance with the requirements of
  the Rehabilitation Act of 1973, as amended, (29
  U.S.C. 794) which states that no otherwise
  qualified individual with a disability shall be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving federal
  financial assistance. The Act requires reasonable
  accommodations for certain persons with
  disabilities.

10
Participation Requirements

• Provides services and supplies to clients in the
  same quality and mode of delivery as provided to
  the general public
• Maintain records for a period of not less than 5
  years (incl. Remits)
• Use Medicaid designated billing forms

11
Participation Requirements

• Reimburse the patient or any other party for any
  monies contributed toward the patient's care from
  the date of eligibility. The only exception is
  when a patient is spending down excess resources
  to meet eligibility requirements.
• Accept assignment of Medicare benefits for
  eligible Medicaid recipients

12
Participation Requirements

• Administrative and financial management capacity
  to meet federal and state requirements
• Ability to maintain business and professional
  documentation
• Furnish to authorized state and federal personnel
  access to records and facilities in the form and
  manner requested

13
Participation Highlights (Contd)

• Be fully compliant with state and federal HIPAA
  confidentiality, use and disclosure requirements

14
Utilization of Insurance Benefits

• Insurance Information- Medicaid is payer of last
  resort. Participating providers are to bill all
  other insurance carriers prior to submitting
  claims to Medicaid
• Workers' Compensation - No Medicaid program
  payments shall be made for a patient covered by
  workers' compensation

15
Termination of Provider Participation

• A provider may terminate with Medicaid at any
  time with written 30 day notice
• Provider must submit written notification of
  voluntary termination to the Director of DMAS and
  First Health Provider Enrollment Unit thirty days
  prior to the effective date

16
Termination of Provider Participation

• Code of Virginia mandates that any such
  (Medicaid) agreement or contract shall
  terminate upon conviction of the provider of a
  felony
• Within 30 days, the provider must notify DMAS of
  the conviction and relinquish the agreement

17
Termination of Provider Participation

• DMAS requests renewal of the Participation
  Agreement prior to its expiration date
• DMAS may terminate a provider upon 30 day written
  notification
• Termination from DMAS shall be treated as an
  adverse action, and the provider shall be
  entitled to a reconsideration and/or hearing

18
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 notice to
  request informal conference)
• The formal evidentiary hearing

19
Eligibility Verification and Billing
20
Medicaid Eligibility
Clients enrolled in the Medicaid Program will be
identified by a Virginia Medicaid Eligibility
Card. Clients enrolled in a Managed Care
Organization (MCO) will also have an
identification card from the MCO. Presence or
absence of a Medicaid card does not guarantee
current eligibility.
21
Medicaid Eligibility

• Before rendering services, providers must always
  verify a clients eligibility.
• If the Medicaid, FAMIS, or FAMIS Plus individual
  does not have either their Medicaid or MCO
  identification card, the provider must verify
  eligibility using the MediCall system, Internet
  Automated Response System (ARS), or one of the
  verification vendors.

22
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
002286
9 9 9 9 9 9 9 9 9 9 9 9
V I RG I N I A J. R E C I P I E N T
DOB 05/09/1964 F
CARD 00001
22
23
Important Contacts

• MediCall
• ARS- Web-Based Medicaid Eligibility
• Provider Call Center
• Provider Enrollment

24
MediCall

• 800-884-9730
• 800-772-9996
• 804-965-9732
• 804-965-9733

25
Automated Response SystemARS

• Web-based eligibility verification option
• Free of Charge
• Information received in real time
• Secure
• Fully HIPAA compliant

26
Provider Sign-up for FreeWeb-based Eligibility
Option

• First Health Services Corporation
• virginia.fhsc.com

27
ARS User Guide Available

• Located on the DMAS web-site under the Whats
  New section
• General information on ARS eligibility
  verification
• Instructions on the using the system
• FAQ(frequently asked questions) section

28
ARS- Information Available

• Medicaid client eligibility
• Service limit information
• Claim status
• Prior authorization
• Provider check log

29
PROVIDER CALL CENTER

• Claims, covered services, billing inquiries
• DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
• 600 East Broad Street, Suite 1300
• Richmond, Virginia
• 800-552-8627
• 804-786-6273

30
Provider Enrollment

• New provider numbers or change of address
• First Health PEU
• P. O. Box 26803
• Richmond, VA 23261
• 888-829-5373
• 804-270-5105
• 804-270-7027 - Fax

31
REQUESTS FOR DMAS FORMS

• DMAS Order DeskCOMMONWEALTH MARTIN1700
  Venable StreetRichmond, Virginia 23222

Phone [phone] Emaildmas_at_cms-mpc.com
32
Billing on the CMS-1500
33
Mailing Address

• Virginia Medical Assistance Program
• P. O. Box 27444
• Richmond, VA 23261

34
FAMIS Enrollees Community Mental Health Services

• Intensive In-Home for Children/Adolescents
• H2021
• Crisis Intervention Mental Health
• H0035 HA
• Day Treatment for Children
• H2011
• Case Management, Targeted Mental Health
• T1017

35
Mailing Address for FAMIS Enrollees ONLY

• ATTN Alisa Amos
• Customer Services Section
• Department of Medical Assistance Services
• 600 East Broad Street
• Richmond, VA 23219

36
TIMELY FILING

• ALL CLAIMS MUST BE SUBMITTED AND PROCESSED
  WITHIN ONE YEAR FROM THE DATE OF SERVICE
• EXCEPTIONS 1. Retroactive
  Eligibility/Delayed Enrollment 2. Previously
  rejected or denied claims
• Submit claims with documentation attached
  explaining the reason for delayed submission.

37
CMS-1500 FORMUse ONLY the originalRED and
WHITE InvoicePhotocopies are not acceptable!
38
Block 1 Check Medicaid
MEDICAID
CHAMPUS
1. MEDICARE
(Medicare )
(Medicaid )
(Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle
Initial)
CHECK MEDICAID BLOCK ONLY
38
39
Block 1a Client ID Number
1a. INSURED'S I.D. NUMBER (FOR PROGRAM
IN ITEM 1)
123456789014
(Be sure to include all 12 digits)
39
40
Block 2 Patient's Name
2. PATIENT'S NAME (Last name, First Name, Middle
Initial)
Smith, Sam
5. PATIENT'S ADDRESS (No., Street)
40
41
Block 10 Accident-Related
10. IS PATIENT'S CONDITION RELATED TO
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
YES
NO
PLACE (State)
b. AUTO ACCIDENT?
YES
NO
c. OTHER ACCIDENT?
NO
YES
You MUST check YES or NO for a, b c
41
42
Block 10D
10d. RESERVED FOR LOCAL USE
ATTACHMENT
You MUST use the word "ATTACHMENT"
if you attach anything to the CMS form.
42
43
Block 21 Diagnosis Codes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3090
1.
3.
29630
2.
4.
May enter up to 4 codes
Omit decimals
43

44
Block 24A Dates of Service
24. A
DATE(S) OF SERVICE
From
To
MM DD YY
MM DD YY
04
04
03
01
03
31
1
03
04
31
31
04
03
2
Both FROM and TO dates
must be completed
Dates must be within same calendar month
44
45
Block 24B Place of Service Block 24C Type of
Service
B
C
Type
Place
of
of
Service
Service
11- Office
11
1
1- Medical Care

45
46
Block 24D Procedure Codes
D
PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS
MODIFIER
H0035
HA
T1017
22
46
47
Block 24E Diagnosis Code
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
3090
1.
3.
29630
2.
4.
E
DIAGNOSIS
CODE
1
Enter the entry identifier of the ICD-9-CM
diagnosis code listed in Locator 21. To identify
more than one diagnosis code, separate the
indicators with a comma.
1,2

48
Block 24 F Charges
F
CHARGES
Enter the usual
and customary charges
48
49
Block 24G Days or Units
G
Enter the number of times or hours the procedure,
service, or item was provided during the service
period.
DAYS
OR
UNITS
2
1

49
50
Block 24I EMG
I
EMG
1-Emergency
If not emergency-
related, leave
blank
50
51
24J COB Other Insurance 24K Other Insurance
Paid
J
K
RESERVED FOR
LOCAL USE
COB
Attach denial from other carrier Attachment in
10d required
52
Block 26 Patients Account Number (Optional)
26. PATIENT ACCOUNT NUMBER
XXXXXXXXXXXXXXXXX
52
53
Block 31 Signature Date
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
SIGNED
DATE
If there is a signature waiver
on file, you may stamp, print,
or computer-generate the signature.
53
54
Block 33 Provider ID and Address
33. PHYSICIAN'S, SUPPLIER'S BILLING NAME,
ADDRESS, ZIP CODE
PHONE
00765432 1
PIN
GRP
Be sure to put the MEDICAID
9-digit ID number!
54
55
Block 22 Adjustments and Voids
22. MEDICAID RESUBMISSION
CODE
ORIGINAL REF. NO.
1026
XXXXXXXXXXXXXXXX
Adjustment or
From original
Void
remittance
Resubmission
Code
55
(See CMS instructions for list of codes)
56
Problems being encountered withCMS-1500 Claims
Submission
BLOCK
PROBLEM AREA
Block 1
Incorrect block checked
Block 1a
Incorrect Client's ID
Block 10d
Incorrect information entered
All of Block 24
Comments entered in blocks
Block 24E
Diagnosis code written out
Blocks 24 J K
(J) left blank (K) incorrect info.
Block 33
Not entering Provider ID by "PIN"
56
57
REMITTANCE VOUCHERSections of the Voucher

• APPROVED - for payment.
• PENDING - for review of claims.
• DENIED - no payment allowed.
• DEBIT (DR)-Adjusted claims creating a
  positive balance.
• CREDIT (CR) - Adjusted/Voided claims
  creating a negative balance.

57
58
REMITTANCE VOUCHERSections of the Voucher

• FINANCIAL TRANSACTION
• EOB DESCRIPTION
• ADJUSTMENT DESCRIPTION/REMARKS- STATUS
  DESCRIPTION
• REMITTANCE SUMMARY- PROGRAM TOTALS.

58
59
Community Mental Health Rehabilitative Services
Training

• Covered Services
• April 2004
• Part II
• www.dmas.virginia.gov

60
Each of the covered COMMUNITY MENTAL HEALTH
SERVICES..

• has specific

• Definition
• Eligibility requirements
• Activities which are required
• Limitations

61
Covered Services and Limitations

• Covered Services are
• Clinically necessary services
• Services provided within the scope of license in
  accordance with the laws that govern the provider

62
When considering any of the Community Mental
Health Rehabilitative Services (CMHRS), 2
questions must be answered

• Does the client/consumer meet the eligibility
  criteria for the specific service?
• and ..
• Does the client/consumer need the service?

63
Intensive In-home Services to Children and
Adolescents (H2021)

• SERVICE DEFINITION
• An EPSDT service
• Time limited interventions in the home
• Services include
• Crisis treatment
• Individual family counseling
• Communication skills counseling
• and/ training
• Case management activities
• 24-hour emergency response
• Home can be family residence or permanent or
  temporary foster care or pre-adoption placement

64
Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT)

• Preventative health care program for children
  under 21
• Services include periodic
• Unclothed physical examination
• Health history
• Vision and hearing assessments
• Age appropriate immunization
• Minimal laboratory tests, including lead screen
• Annual referral to a dentist starting at age 3
• Appropriate referral for health problem detected

65
Intensive In-home Services to Children and
Adolescents (H2021)Eligibility Criteria
Chapter IV, p. 3, 4

• Two of the following must be documented for the
  individual on a continuing or intermittent
  basis..
• Difficulty in establishing/maintaining normal
  interpersonal relationships to such a degree that
  they are at risk of hospitalization or
  out-of-home placement because of conflicts with
  family or community

66
Intensive In-HomeEligibility Criteria
(contd)

• Exhibit such inappropriate behavior that
  repeated interventions by the mental health,
  social services or judicial system are necessary
• Exhibit difficulty in cognitive ability such
  that they are unable to recognize personal danger
  or recognize significantly inappropriate social
  behavior.

67
Intensive In-HomeEligibility Criteria
(contd)

• Out-of-home placement is a risk and either
• Services that are far more intensive than
  outpatient clinic care are required to stabilize
  the child in the family situation
• OR
• The childs residence as the setting for
  services is more likely to be successful than a
  clinic,
• AND

68
Intensive In-HomeEligibility Criteria
(contd)

• At least one parent with whom the child is living
  must be willing to participate in in-home
  treatment, with the goal of keeping the child
  with the family.
• These services may also be used to facilitate the
  transition to home from an out-of-home placement.

69
Intensive In-Home Limitations

• Case Management Services cannot be billed
  separately
• Service is not appropriate for a family..
• while the child is not living in the home
• OR
• being kept together until an out-of-home
  placement can be arranged
• Staff travel time is excluded
• Caseload is limited to 6 or fewer cases

70
Therapeutic Day Treatment for Children
Adolescents (H0035-HA)

• SERVICE DEFINITION
• Psychotherapeutic interventions combined with
  education and mental health treatment
• Offered in programs of 2 or more hours per day
  with groups of children/adolescents

71
Therapeutic Day Treatment for Children
Adolescents Criteria

• The individual must demonstrate a
• clinical necessity for the service similar to
  Intensive In-Home Service
• AND
• Require year-round treatment in order to sustain
  behavioral or emotional gains
• or
• Behavior/emotional problems so severe

72
Therapeutic Day Treatment for Children
Adolescents Criteria (contd)

• or
• Behavior/emotional problems so severe they cannot
  be handled in self-contained or special
  classrooms (ED) without this programming during
  the school day or as a supplement to the school
  day/year
• or
• Would otherwise be placed on homebound
  instruction
• or

73
Therapeutic Day Treatment for Children
Adolescents Criteria (contd)

• or
• Have deficits in
• social skills
• peer relations
• dealing with authority
• are hyperactive
• have poor impulse control
• are extremely depressed
• marginally connected with reality
• or

74
Therapeutic Day Treatment for Children
Adolescents Criteria (contd)

• or
• (Children in preschool enrichment early
  intervention programs) when the childs
  emotional/behavioral problems are so severe, they
  cannot function in these programs without
  additional services

75
Therapeutic Day Treatment For Children
Adolescents Limitations

• Time for academic instruction when no treatment
  activity is going on cannot be included in the
  billing unit
• A maximum - 780 units per year
• Staff travel time is excluded

76
Day Treatment/Partial Hospitalization
(H0035-HB)

• SERVICE DEFINITION
• Programs of 2 or more consecutive hours a day
• May be multiple times per week
• Provided to groups of individuals in a
  non-residential setting

77
Day Treatment/Partial Hospitalization Criteria

• The individual must demonstrate
• clinical necessity for the service arising
  from a
• mental
• behavioral
• emotional
• illness resulting in significant functional
  impairments in major life activities

78
Day Treatment/Partial HospitalizationRequired
Activities

• This service is designed for
• individuals with serious mental disorders
• individuals who require
• coordinated
• intensive
• comprehensive
• multi-disciplinary treatment
• individuals who do not require inpatient
  treatment

79
Psychosocial Rehabilitation (H2017)

• SERVICE DEFINITION
• Programs of 2 or more consecutive hours per day
• Provided to groups of adults in a
  non-residential setting

80
Psychosocial RehabilitationRequired Activities

• Progress notes must be completed at least monthly
• Attendance may be documented through the use of
  sign-in sheets or logs that include the arrival
  and departure times and a staff signature

81
Psychosocial RehabilitationRequired Activities
(contd)

• Opportunities to enhance social and interpersonal
  skills within a supportive and normalizing
  program structure and environment
• The program must operate a minimum of 2
  continuous hours in a 24-hour period.
• Coordination with the Case Management Agency (if
  applicable)

82
Psychosocial Rehabilitation Limitations

• Time for field trips (off-site activities) IS
  allowed if the goal is
• to provide supervised socialization skills
  within the context of therapeutic recreation
  training in an integrated setting
• and
• to increase the consumers understanding or
  ability to access community resources

83
Psychosocial Rehabilitation Limitations

• A maximum of 936 units may be billed per year
• Staff travel time is excluded
• Vocational services are not reimbursable

84
Intensive Community Treatment (H0039)

• SERVICE DEFINITION
• Intensive Community Treatment (ICT) is an array
  of mental health services for adults
• with a serious emotional illness
• who need intensive levels of support service
• in their natural environment to permit or
  enhance functioning in the community

85
Intensive Community Treatment Criteria

• At high risk for psychiatric hospitalization
  because of inappropriate social behavior
• Demonstrates a resistance to seeking treatment
• Treatment available directly/on call 24 hrs-365
  days per year

86
Intensive Community TreatmentLimitations

• The service is initially covered for a maximum of
  26 weeks. Continuation can occur if authorized
  for an additional 26 weeks annually
• A unit equals one hour
• To reach a billable Unit, time may be
  accumulated
• There is a limit of 130 units annually

87
Intensive Community Treatment Limitations

• Any services provided to an ICT client in the
  mental health clinic, such as crisis
  stabilization, or case management, should be
  billed as ICT.

88
Crisis Intervention (H2011)

• SERVICE DEFINITION
• Mental health care, available 24 hours a day, 7
  days per week, to provide assistance to
  individuals experiencing acute mental health
  dysfunction requiring immediate clinical
  attention

89
Crisis Intervention Objectives

• to prevent exacerbation of a condition
• to prevent injury to the consumer or others
• and
• to provide treatment in the least
  restrictive setting

90
Crisis Intervention Limitations

• A Unit 15 minutes
• A Maximum of 720 units of Crisis Intervention can
  be provided annually
• A face-to-face contact with the consumer must
  occur during the crisis episode

91
Crisis Intervention Limitations (contd)

• Other contacts, such as telephone calls and
  collateral contacts during the crisis episode,
  are reimbursable as long as the requirement for a
  face-to-face contact is met and the contacts are
  directed toward crisis resolution.
• Reimbursement will be provided for short-term
  crisis counseling contacts scheduled within a
  30-day period from the time of the first
  face-to-face crisis contact.

92
Crisis Intervention Limitations (contd)

• IMPORTANT
• Medicaid cannot be billed when a recipient is
  under Emergency Custody Orders (ECOs) or
  Temporary Detention Orders (TDOs).
• Services may be billed
• up to the time an order is received
• After ECO, if ECO ends with no TDO
• after evaluation for ECO/TDO is complete
• Documentation must clearly delineate the
  separation of time.

93
Crisis Stabilization (H2019)

• SERVICE DEFINITION
• Direct mental health care
• To non-hospitalized individuals of all ages who
  are experiencing an acute crisis of a psychiatric
  nature that may jeopardize their current
  community living situation

94
Crisis Stabilization (contd)

• GOALS
• Avert hospitalization or rehospitalization
• Provide normative environments with a high
  assurance of safety security for crisis
  intervention
• Stabilize individuals in psychiatric crisis
• Mobilize the resources of the community support
  system, family members others for on-going
  maintenance rehabilitation

95
Crisis Stabilization Limitations

• Service is neither appropriate nor reimbursed for
  individuals with
• medical conditions which require hospital care
• a primary diagnosis of substance abuse
• or
• psychiatric conditions which cannot be managed in
  the community, such as individuals who are of
  imminent danger to self or others

96
Crisis Stabilization Limitations

• NOT a part of this service
• Room and board
• Custodial care
• General supervision
• Staff travel time

97
Crisis Stabilization Limitations

• There is a limit of 8 hours a day for up to 15
  consecutive days in each episode, up to 60 days
  annually
• No concurrent billing is allowed during the same
  time period for clinic option outpatient mental
  health services

98
Mental Health Support (H0046)

• SERVICE DEFINITION
• Training and support to enable individuals with
  significant functional limitations
• to achieve and maintain community stability
  and independence
• in the most appropriate, least restrictive
  environment

99
Mental Health Support Eligibility Criteria

• Individuals must demonstrate a clinical need for
  this service arising from a condition due to
  mental, behavioral, or emotional illness which
  results in significant functional impairments in
  major life activities.

100
Mental Health Support - Eligibility Criteria
(contd)

• Individuals must meet at least two of the
  following on a continuing or intermittent basis..

• Difficulty in establishing or maintaining normal
  interpersonal relationships
• At risk of hospitalization
• Or
• homelessness
• because of conflicts with family/community

101
Mental Health Support - Eligibility Criteria
(contd)

• Require help in basic living skills
• maintain personal hygiene
• prepare food
• maintain adequate nutrition
• manage finances
• HEALTH OR SAFETY IS JEOPARDIZED

• Exhibit inappropriate behavior
• Immediate interventions by the community have
  been necessary
• mental health agencies
• social service agencies
• judicial system

102
Mental Health Support - Eligibility Criteria
(contd)

• Exhibit difficulty in cognitive ability
• Unable to recognize...
• personal danger
• OR
• significantly inappropriate social behavior

103
Mental Health Support - Eligibility Criteria
(contd)

• The individual must have had at least one
  psychiatric hospitalization
• This may include individuals with a dual
  diagnosis of either
• mental illness and mental retardation
• OR
• mental illness and substance abuse disorder

104
Mental Health Support Limitations

• NOT a part of this service
• Academic service
• Vocational services
• Room and board
• Custodial care
• General supervision

105
Mental Health Support Limitations (Contd)

• Individuals who reside in facilities whose
  license requires that staff provide all necessary
  services are not eligible for this service
• Only direct face-to-face contacts and services to
  the recipient are reimbursable
• There is a limit of 31 units in a month

106
Substance Abuse for Pregnant WomenResidential
(H0018-HD)Day Treatment (H0015-HD)

• SERVICE DEFINITION
• Comprehensive intensive intervention services in
  a residential facility or central location
  lasting 2 hours per day, OTHER than an inpatient
  facility
• For pregnant and postpartum women with serious
  substance abuse problems

107
Residential Limitations

• Residential capacity shall be limited to 16
  adults
• No services may be provided to children
• The minimum ratio of clinical staff to women
  shall assure sufficient staff to address the
  needs of the woman
• Days of unauthorized absence cannot be billed

108
Residential Limitations

• No reimbursement for any other Community Mental
  Health/Mental Retardation/Substance Abuse
  rehabilitative services are available while the
  individual is participating in this program
• There is a limit of 330 days of continuous
  treatment, once per lifetime, not to exceed 60
  days postpartum
• Unauthorized absence of less than 72 hours is
  included in this limit

109
Day Treatment Limitations

• Only mental health crisis intervention services
  or mental health crisis stabilization may be
  reimbursed for recipients of day treatment
  services
• More than two episodes of five-day absences from
  scheduled treatment without prior permission from
  the program director, or one absence exceeding
  seven (7) days of scheduled treatment without
  prior permission from the program director, shall
  terminate the services

110
Day Treatment Limitations

• Limit of 440 UNITS in a 12-month consecutive
  period, once in a lifetime, not to exceed 60 days
  postpartum

111
Mental Health Case Management (T1017)

• SERVICE DEFINITION
• Mental Health Case Management ASSISTS individual
  children, adults and their families
  with
• ACCESSING needed medical, psychiatric, social,
  educational, vocational, and other supports
  essential to meeting basic needs

112
Mental Health Case Management

• POPULATION DEFINITION
• 1. Serious Mental Illness
• 2. Serious Emotional Disturbance
• 3. At Risk of Serious Emotional Disturbance

113
Mental Health Case Management Services Criteria

• Documentation of the presence of
• Serious Mental Illness (adult) OR
• Serious Emotional Disturbance or Risk of
  Serious Emotional Disturbance (child/adolescent)
• The individual must require case management as
  documented on the ISP (developed by a qualified
  mental health case manager)

114
Mental Health Case Management Services Criteria

• Must be an active client
• a plan of care which requires regular
  direct/client-related contacts
  communication/activity
• a minimum of ONE face-to-face contact every
  90 days

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Mental Health Case Management Limitations

• Billing can be submitted for case management only
  for months in which direct or client-related
  contacts, activity, or communications occur
• Reimbursement is provided only for active case
  management consumers

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Mental Health Case Management Limitations

• Case management reimbursement for individuals age
  21-64 in an Institution for Mental Disease (IMD)
  is not allowed
• There is no maximum service limit for case
  management services EXCEPT for consumers residing
  in institutions/medical facilities ...

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Mental Health Case Management Limitations

• Case management MAY be provided to
  institutionalized individuals as long as 2
  conditions are met
• Services cannot be duplicated by the
  institutional discharge planner,
• AND
• Community case management services are limited
  to 1 month of service 30 days prior to discharge
  from the facility.

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Mental Health Case Management Limitations

• Case management for institutionalized individuals
  may be billed for no more than 2 non-consecutive
  pre-discharge periods in 12 months
• Case Management services for the same individual
  must be billed by only ONE type of case
  management provider

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• Federal regulations require that DMAS review and
  evaluate the services provided through the
  Medicaid program

120
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
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General UR Facts

• Reviews are initiated on a regular basis to meet
  federal requirements or by referrals and
  complaints from agencies or individuals

• Reviews are unannounced

• A random sample from the provider's Medicaid
  billing is selected for review

• An expanded review may be conducted if an
  excessive number of exceptions or problems are
  identified

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Your UR Site Visit

• Record Review will include
• Request to review program and billing records in
  a central location
• The Review may include
• Observation of service delivery
• Face-to-face or telephone
  interviews with the consumer
  and/or family
• Review of staff qualifications

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

124
The UR Golden Rule

• Delivered services as documented are consistent
  with the recipients plan of care, submitted
  invoices and specified service limitations.

125
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

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Individual Service Plan

• The ISP should state the following information
  for each goal/objective
• why the goal/objective is needed
  (problem/need statement)
• the desired outcome
• strategies for service intervention
• the staff person responsible for the intervention
• target date for accomplishment
• planned frequency of staff activity

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GOALS vs. OBJECTIVES

• GOALS are broad, generalized statements about
  what is to be learned

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OBJECTIVES

• MEASURABLE
• ACHIEVABLE
• SPECIFIC BEHAVIOR
• TARGET DATE

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OBJECTIVES

• WHO is going to do something?
• WHAT are they going to do?
• WHAT strategy/intervention are they going to use?
• HOW often are they going to do it?
• WHO is going to monitor progress?
• HOW are you going to measure success?
• WHAT is the target date for success?

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www.dmas.virginia.gov