3Resources DHSS/BH Website: http://health.hss.state.ak.us/dbh/ Training MaterialsDocuments & PublicationsFormsFAQ’sRegulationsLinks
4Regulations Clarification Process Procedure for Providers to inquire about meaning or applicability of BH Services RegulationsMechanism for DHSS/BH to explain (FAQ) or interpret (Clarification) BH Services RegulationsMethod for compiling information leading to updates in Manual and potential revisions of BH Services RegulationsThe Regulations Clarification Process is designed to help Providers get questions answered about the meaning of any sentence, phrase or section of the regulations, especially as they apply to other Dept. requirements or business procedures.The Dept. has established a formal internal mechanism to fully research and develop responses to these inquiries. This internal review may result in a simple explanation of the meaning and intent of the regulations, or it could result in a formal interpretation of the regulations which provides greater direction or establishes applicability. Simple or common explanations will typically result in an addition to our Frequently Asked Questions document(s). Formal interpretations become published Regulation Clarifications that have operational authority.The Regulations Clarification Process will also assist the Dept. to compile thematic information over time that may help shape future revisions of the regulations. Revisions typically clarify and strengthen regulations and reduce the need for long lists of interpretations.
5Regulations Clarification Cont. Procedure:Provider completes & submits FormDHSS/BH staff researches question & develops recommended responseDHSS/BH Executive Team reviews, edits and approves responseDHSS/BH staff posts response as FAQ on website, and informs Provider; ORPublishes response as Clarification in Billing Manual, and informs ALL Providers.Providers can submit questions they have about the regulations in a number of ways. A Form for requesting a clarification exists on our website and is included in the Medicaid Provider’s BH Services Manual. Providers may complete these forms on-line, or print them out and FAX them to the Division. Providers may also ask any DBH professional staff to assist them to complete and submit the form.Once a Form has been submitted the provider’s question is examined by subject matter experts within the Dept. who research all supporting Statutes, Codes, documents and references and consult as needed with Dept. leadership and legal advisors to develop a written response which is submitted to a Team of Executives for review and approval.When a written response has been formally approved by the Executive Team, it is shared with the Provider who submitted the inquiry and then circulated to all other Providers and Dept. staff. Formal Regulation Clarifications are submitted to the Dept’s Fiscal Agent for inclusion in the Billing Manual.The process from inquiry to response and publication will take approximately 14 business days.
7Definition 7AAC (b)(95)“Mental health physician clinic means a clinic, operated by one or more psychiatrists, that exclusively or primarily provides mental health clinic services furnished by a psychiatrist or by one or more qualified professionals.”
8Qualified Professional Licensing RegulationLicensed Psychologist7AACLicensed Psychological AssociateAS 08.86Licensed Clinical Social WorkerAS 08.95Licensed Physician Assistant7AACLicensed Advanced Nurse Practitioner7AACLicensed Psychiatric Nursing Clinical SpecialistAS 08.68Licensed Marital & Family TherapistAS 08.63Licensed Professional CounselorAS 08.29
9MHPC Requirements: 7 AAC 135.030 Must be enrolled in Medicaid under 7 AACServices are for treatment of a diagnosable mental health disorder;Services provided by psychiatrist or licensed professionalsPsychiatrist operating MHPC provides direct supervision to staff and assumes responsibility for the treatment given.Necessary adjunctive treatment provided directly or through written agreement with a MHPC or other member of the MHPC staffServices provided on MHPC premises or via telemedicine under 7 AAC AAC , unless the service:could not otherwise be provided; oris provided at a location clinically more appropriate than MHPC;c. reason that service was provided in alternate location or via telemedicine is clearly documented in recipient's clinical record.
10MHPC Requirements: 7 AAC 135.030 Psychiatrist operating MHPC must provide direct supervision to each qualified staff.Direct supervision means:Psychiatrist on premises to deliver medical services at least 30 % of operating hoursApprove all treatment plans in writingReview each case every days to determine the need for continued careProvide direct clinical consultation and supervisionAssure services provided are medically necessary and clinically appropriateAssume professional responsibility for services provided.Notice the difference in the amount of time the psychiatrist is required to be on premise.
12Clinic Service Limits & Requirements A MHPC may provide the following behavioral health clinic services without prior authorization from the department per recipient / per State fiscal year:Psychotherapy: 10 hours (any combination of individual, group, and family)Psychiatric assessments: 4 assessmentsPsychological testing and evaluation: 6 hoursNeuropsychological testing and evaluation: 12 hours (must document provider's qualifications to provide neuropsychological testing and evaluation services)Pharmacologic management services: 1 visit per week (first four weeks) / 1 visit per month thereafter, unless more frequent monitoring is required because:a. the requirements of the specific medication; orb. a recipient's unusual clinical reaction to a medicationAssessment: 1 Integrated mental health and substance use intake assessment, OR 1 Mental health intake assessment every six months.Short-term crisis intervention services: 22 hoursScreening and brief intervention services (SBIRT): 1 billable service / per day
13PaymentIf a physician provides clinic services in a MHPC, the physician may submit a claim for payment:using the MHPC medical assistance provider identification number (payment subject to requirements and restrictions placed on MHPC) ORusing the physician's medical assistance provider identification number (payment subject to requirements and restrictions placed on a physician)NOTE: Services must be medically necessary and clinically appropriate and must be rendered directly by the physician.
14Mental Health Intake Assessment A Mental Health Intake Assessment must be:1. Conducted by a mental health professional clinician2. Conducted upon admission to services & updated as new information becomes available3.Conducted for the purpose of determining:a. recipient’s mental status, social and medical historiesb. nature & severity of any mental health disorderc. complete multi-axial DSM diagnosisd. functional impairmentse. treatment recommendations to form Tx PlanSee 7 AAC for more information on documentation
15Integrated Mental Health and Substance Use Intake Assessment Documented in accordance with 7 AAC (Clinical Record)Conducted by a mental health professional clinician:Upon admission to services & during the course of active treatment as necessary;Updated as new information becomes availableConducted for the purpose of determining:All the requirements of a Mental Health Intake AssessmentIf the recipient has a substance use disorderNature & severity of any substance use disorder7 AAC (92) defines functional impairment to mean:a disorder that substantially interferes with or prevents a recipient from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills;includes disorders of episodic, recurrent, or continuous duration;does not include temporary, expected responses to stressful events in the recipient’s envioronment.
16Psychiatric Assessments “The Dept. will pay a MHPC for a psychiatric assessment that may serve as the Professional Behavioral Health Intake Assessment if the recipient's condition indicates the need for a more intensive assessment, including an assessment to evaluate the need for medication.”A psychiatric assessment must be conducted by a licensed practitioner who is:Physician, Physician Asst., Advanced Nurse Practitionerworking within the scope of their education, training, and experiencehas prescriptive authorityenrolled under 7 AAC (c) as a dispensing provider
17Psychiatric Assessments Cont. Both types of Psychiatric Assessments must include:a review of medical & psychiatric history or presenting problem;a relevant recipient history;a mental status examination;a complete multi-axial DSM diagnosis;a listing of any identified psychiatric problems, including functional impairments;treatment recommendations.
18Psychological Testing and Evaluation “The Dept. will pay a MHPC, or psychologist for psychological testing and evaluation to assist in the diagnosis and treatment of mental and emotional disorders.”Psychological testing and evaluation includes:the assessment of functional capabilitiesthe administration of standardized psychological teststhe interpretation of findings.
19Pharmacologic Management “The Dept. will pay a MHPC for a pharmacologic management service if that service is provided directly by a professional described in 7 AAC (b)(2).”To qualify for payment, a provider must monitor a recipient for the purposes of:1. assessing a recipient's need for pharmacotherapy;2. prescribing appropriate medications to meet the recipient's need; and3. monitoring the recipient's response to medication, including:a. documenting medication compliance;b. assessing & documenting side effects;c. evaluating & documenting effectiveness ofthe medication.
20Psychotherapy “The department will pay a MHPC for one or more of the following forms of psychotherapy, as codedin Current Procedural Terminology (CPT):”insight-oriented individual psychotherapy;interactive individual psychotherapy;group psychotherapy;family psychotherapy - without recipient;family psychotherapy - with recipient;multi-family group psychotherapy.
21Psychotherapy Clarification Biofeedback or relaxation therapy may be provided as an element of insight-oriented and interactive individual psychotherapy if:1. prescribed by a psychiatrist (if provided in MHPC)2. included in the behavioral health treatment plan as a recognized treatment or adjunct to a treatment only for the following conditions or substantially similar conditions:a. chronic pain syndrome;b. panic disorders;c. phobias.
22Short-Term Crisis Intervention “The Dept. will pay a MHPC for short-term crisis intervention services, provided by a mental health professional clinician to a recipient, if that mental health professional clinician provides an initial assessment of:the nature of the short-term crisis;recipient's mental, emotional, and behavioral status;recipient's overall functioning in relation to the short- term crisis.”A MHPC is NOT required to use Dept. form to document short-term crisis intervention.A MHPC may bill the same number of hours for service as a CBHS Provider/22hrs. per SFY
23Facilitation of Telemedicine “The department will pay a MHPC for facilitation of a telemedicine session if the facilitating provider:1. provides the telemedicine communication equipment;2. establishes the electronic connection used by treating provider and recipient;3. remains available during session to reestablish the electronic connection if it fails before the intended end of the telemedicine session.”The facilitating provider must make a note in the recipient's clinical record summarizing the facilitation of each telemedicine session.The facilitating provider is not required to document a clinical problem or treatment goal in the note.
24Screening & Brief Intervention “The Dept. will pay a MHPC for screening and brief intervention services if staff conducts the screening component and brief intervention utilizing self- report questionnaires, structured interviews (or similar screening techniques) to detect substance use problems and to identify the appropriate level of intervention.”
25Screening & Brief Intervention (con’t) Brief intervention is motivational discussion focused on:raising awareness of recipient’s substance usethe potential harmful effects of substance useencouraging positive changeBrief intervention may include:FeedbackGoal settingCoping strategiesIdentification of risk factorsInformation & advice
26Screening & Brief Intervention (con’t) MHPC must refer to appropriate program that will meet recipient’s needs if:Screening reveals severe risk of substance useRecipient is already substance use dependentRecipient already received SBIRT and was unresponsiveMHPC must document SBIRT in progress noteSBIRT does not require assessment or Tx. Plan
28Clinical Record Requirements The clinical record must include: An assessmentA behavioral health treatment plan that meets the requirements of 7AAC ;A progress note for each day the service is provided, signed by the individual providerMust reflect all changes made to the recipient’s treatment plan & assessment.Must set out a description or listing of the active interventions that the provider provides to, or on behalf of the recipient in order to document active treatment.
29Treatment PlanDocumented in accordance with 7 AAC (clinical record)Based on a behavioral health assessmentDeveloped with the recipient or recipient’s legal representative (18 and older)Based upon the input of a Treatment Team if the recipient is a child (under 18)Signed and supervised by psychiatrist operating MHPC, and by the recipient or the recipient’s parent or legal representative.Reviewed every days to determine need for continued care
30Treatment Plan Documentation Recipient’s identifying informationThe date implementation of plan will beginTreatment goals that are directly related to the findings of the assessmentThe services and interventions that will be rendered to address the goalsThe name, signature, and credentials of the psychiatrist operating MHPCThe signature of the recipient or the recipient’s parent or legal representativeWe received the following question:7AAC (e) indicates that the psychiatrist approves the behavioral health treatment plan and reviews it every 90 – 135 days to determine need for continued care. Does the clinician who provides services and creates the Behavioral Health Treatment Plan have to provide a written Treatment Plan Review every 90 days as requested in previous regulations?a. No, the previous regulations requirement is no longer in effect.
31Treatment TeamAs it applies to a MHPC, a behavioral health treatment team for a recipient under 18 must include:The recipientThe recipient’s family members, including parents, guardians, and others involved in providing general oversight to the clientA staff member from OCS if the recipient is in state’s custodyA staff member from DJJ if the recipient is in their custody[Licensed] clinic staffA behavioral health treatment team for a recipient under 18 may include:Representative(s) from alternative living arrangements, including foster care, residential child care, or an institutionRepresentative(s) from the recipient's educational system
32Treatment Team Cont.All members of treatment team shall attend meetings of the team inperson or by telephone and be involved in team decisions unless the clinical record documents that:the other team members determine that participation by the recipient or other individual involved with the care of the recipient is detrimental to the recipient's well-beingfamily members, school district employees, or government agency employees refuse to or are unable to participate after the provider's responsible efforts to encourage participation orweather, illness, or other circumstances beyond the member's control prohibits that member from participating
33Progress Notes7AAC (8) Requires:Documented progress note for each service, each day service is providedDate service was providedDuration of the service expressed in service units or clock timeDescription of the active treatment provided (interventions)Treatment goals that the service targetedDescription of the recipient’s progress toward treatment goalsName, signature, and credentials of the individual who rendered the service
35Medicaid is Payer of Last Resort If the recipient is covered /eligible for benefits by other public or private health plan, that plan must be billed before billing MedicaidMedicare recipients with “Dual Eligibility” under both programs (i.e. disabled adults and adults over age 65) may be eligible under both Medicare and MedicaidMilitary and Veteran’s BenefitsPrivate Health InsuranceThe recipient’s card/coupon will include Resource Code and/or Carrier Code to designate this coverage
36Behavioral Health Medicaid Payment Before Medicaid can pay for Behavioral Health Services, the individual must be eligible for Medicaid.There are various paths to Medicaid eligibility and the Division of Public Assistance is responsible for determining eligibility for all categories, except children in State Custody.The provider should request to see proof of eligibility at the time of service by viewing the recipient’s coupon or card issued by Division of Public Assistance (Medicaid coupon, Denali KidCare Card)
37CAMA CAMA is the acronym for Chronic and Acute Medical Assistance. CAMA IS NOT Medicaid, CAMA is:100% state fund Medical Assistance for a limited number of health conditions, andHas very limited coverageMHPC are not covered by CAMACAMA coverage also includes limits the number of medications a person can receive in a month
38Medicaid Program Policies & Claims Billing Procedures Manual Section I – Program Policies and Claims Billing Procedures for MHPC ServicesPART A – General RequirementsPART B – Service Detail SheetsSection I Appendices• Appendix I-A – Medical Assistance Provider Enrollment and Provider Agreement• Appendix I-B – Medical Assistance Recipient Eligibility• Appendix I-C – Clinical Documentation Requirements• Appendix I-D – Billing and Payment Information• Appendix I-E – Regulations Clarification of Integrated BH Services RegulationsSection II – Attachments and RemittancesAttachmentsSupplemental documentsRemittance Advice (RA) ReconciliationAdjustments/VoidsClaim InquiryForms OrderSection III – General Medical Assistance Information• Claims Processing Overview• Eligible Recipients for ALL programs• General Program Regulations and Restrictions
39Services New Codes/ Services Changing Services/ Codes Code Service DescriptionH0031-HHIntegrated Mental Health & Substance Use Intake AssessmentQ3014Facilitation of Telemedicine90846Psychotherapy, Family w/ out patient presentS9484-U6Short-Term Crisis Intervention (15 min)99408Screening, Brief Intervention & Referral for TreatmentCodeDescriptionChangeH0031Mental Health AssessmentUnits were based on time with 3 hr maxNow based on 1 assessment, payable at flat rate90849Psychotherapy Multi Family GroupChange in RateRate was $ per hourRate is now $ per hour
40Service Authorization Annual Service Limits will switch from CALENDAR year to STATE FISCAL yearAll Existing Prior Authorization records currently in Medicaid Management Information System (MMIS) will be updated with an END DATE of 11/30/2011 to facilitate this changeRequests to be made in correlation with requirement to review each case to determine need for continued treatmentRequests will cover a maximum of 90 to 135 days of planned services and will be submitted approximately 3 to 4 times annuallySERVICE AUTHORIZATION is an updated industry term for what we’ve all known as PRIOR AUTHORIZATION. This updated term de-emphasizes the timeframe of the request and is more descriptive of what the actual focus of the review is---whether or not the service or services requested in excess of the Medicaid program’s annual service limits is medically necessary and should or should not be authorized.Basically, you get a blank slate starting on December 1, 2011 for service authorization beyond limitations.This slide does include some changes:Calculation of annual limits will change from calendar year to state fiscal yearRequests for authorization to exceed annual limits will include no more than 4 months of planned services and therefore need to be submitted for review 3 times per year.We received the following question: Please explain the changes in the fiscal year – We’re starting on December 1, 2011. Is December 1, 2011 to June 30, 2012 considered a fiscal year for the start of the new regulations?a. Yes. Thereafter the State fiscal year runs from July 1 – June 30.
41How to find Alaska Medicaid Information using Affiliated Computer Services, Inc (ACS) Website start at the fiscal agent’s Alaska Medical Assistance page (http://www..medicaidalaska.com)select “Providers" located in the horizontal list at the top of the pageselect “Billing Manuals" click on the boxed word “Accept” at the bottom of the page to indicate your agreement and acceptance of the copyright noticeClaim form instructionsCMS-1500 Professional Services (Set B is for use by outpatient behavioral health services providers)UB-04 Institutional Services (inpatient and residential psychiatric treatment center servicesProgram Policies & Claims Billing Procedures Manuals for all covered services are listed alphabeticallyMental Health Physician ClinicOther Service Providers (Physician, Advanced Nurse Practitioner, Federally Qualified Health Center, School Based Services)select “Forms"Provider Enrollment Application formsInformation Submission AgreementsService Authorization Formsselect “Updates”Manual replacement pagesselect “HIPAA"Companion Guides for all Electronic TransactionsTool kit , testing procedures, and other information for becoming an electronic submitter/receiverselect “Training" to view the training schedule, register for a class or view past materialsselect “Contact Us” for designated work units, staff, mailing addresses, etc.
42Fiscal Agent Functions Processes all Medical Assistance claims, including technical support to accommodate electronic submission of claims and other transactionsProvides customer service for providers and recipientsEnrolls providers in Medical AssistanceProvides Medical Assistance billing training to the provider communityPublishes and distributes program policy & billing manualsMaintains website of information for providersAuthorizes some servicesPerforms First Level Provider AppealsPerforms Intake for Recipient Fair Hearing RequestsGenerates and issues claim payments and tax informationPerforms Surveillance and Utilization Review (program integrity)
43Claims Billing and Payment Tools & Support Program Policy & Billing ManualsProvider TrainingProvider Inquiry; Enhanced Provider Support Chandra Lewis in-state, toll free: (800) or Anchorage (907)Websites– Fiscal Agent (ACS)– DHSS/DBH– DHSS/DHCSTechnical Support for Electronic Claims
44Claims Filing LimitsALL CLAIMS MUST BE FILED WITHIN 12 MONTHS OF THE DATE SERVICES WERE PROVIDED TO THE PATIENT!The 12-month timely filing limit applies to all claims, including those that must first be filed with a third party carrier.
45Claims EditingAll edits are three-digit codes with explanations of how theclaim was processed– Adjudicated Claims (Paid or Denied)• reduction in payment• denial of service– In-process claims (further internal review or information needed)• pending status requiring internal staff review• additional information requested from the provider (via RTD)The Remittance Advice (RA) statement includes anExplanation of Benefit (EOB) description page that lists allEOB codes and a brief description of each found within thatspecific Remittance Advice- Contact ACS, Inc. Provider Inquiry for clarification as needed
46Claims Adjudication Process Flow Integrated BH Regulations Training
47Provider Appeals REASONS to Request an Appeal Three Levels of Appeals Denied or reduced claims (180 days)Denied or reduced prior authorization (180 days)Disputed recovery of overpayment (60 days)Three Levels of AppealsFirst level appealsSecond level appealsCommissioner level appeals
48Recommend Billing Processes Read and maintain your billing manualVerify recipient eligibilityVerify eligibility codeVerify dates of eligibilityVerify Third Party LiabilityVerify the services you are eligible to provideVerify procedure codesObtain Service Authorization, if applicableFile your license renewals and/or certification/permits timely (keep your enrollment current)Ensure completion of claim forms (reference provider manual)Document Third Party Liabilitypayment on claim, if applicableInclude attachments as requiredFILE TIMELYRECONCILE PAYMENTSRead and distribute RA messagesAddress problems/issuespromptlyCall Provider Inquiry withquestionsTHIS SLIDE DEVELOPED TO SHOW YOU THE MAJOR COMPONENTS OF ACHIEVING SUCCESS IN BILLING CLAIMSELIGIBILITYCLAIM FORM COMPLETIONTIMELY FILINGCOMMUNICATION WITH FH*This is a great reference tool for you!!!!First thing is to verify eligibility