Presentation on theme: "Mental Health Physician Clinic Training on the Integrated Behavioral Health Services Regulations."— Presentation transcript:
Mental Health Physician Clinic Training on the Integrated Behavioral Health Services Regulations
DHSS/BH Website: Training Materials Documents & Publications Forms FAQs Regulations Links
Regulations Clarification Process 1.Procedure for Providers to inquire about meaning or applicability of BH Services Regulations 2.Mechanism for DHSS/BH to explain (FAQ) or interpret (Clarification) BH Services Regulations 3.Method for compiling information leading to updates in Manual and potential revisions of BH Services Regulations
Regulations Clarification Cont. Procedure: 1.Provider completes & submits Form 2.DHSS/BH staff researches question & develops recommended response 3.DHSS/BH Executive Team reviews, edits and approves response 4.DHSS/BH staff posts response as FAQ on website, and informs Provider; OR 5.Publishes response as Clarification in Billing Manual, and informs ALL Providers.
Definition 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.
Qualified ProfessionalLicensing Regulation Licensed Psychologist7AAC Licensed Psychological AssociateAS Licensed Clinical Social WorkerAS Licensed Physician Assistant7AAC Licensed Advanced Nurse Practitioner7AAC Licensed Psychiatric Nursing Clinical Specialist AS Licensed Marital & Family TherapistAS Licensed Professional CounselorAS 08.29
MHPC Requirements: 7 AAC Must be enrolled in Medicaid under 7 AAC Services are for treatment of a diagnosable mental health disorder; 3.Services provided by psychiatrist or licensed professionals 4.Psychiatrist operating MHPC provides direct supervision to staff and assumes responsibility for the treatment given. 5.Necessary adjunctive treatment provided directly or through written agreement with a MHPC or other member of the MHPC staff 6.Services provided on MHPC premises or via telemedicine under 7 AAC AAC , unless the service: a.could not otherwise be provided; or b.is 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.
MHPC Requirements: 7 AAC Psychiatrist operating MHPC must provide direct supervision to each qualified staff. 2.Direct supervision means: A.Psychiatrist on premises to deliver medical services at least 30 % of operating hours B.Approve all treatment plans in writing C.Review each case every days to determine the need for continued care D.Provide direct clinical consultation and supervision E.Assure services provided are medically necessary and clinically appropriate F.Assume professional responsibility for services provided.
Clinic 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: 1.Psychotherapy: 10 hours (any combination of individual, group, and family) 2.Psychiatric assessments: 4 assessments 3.Psychological testing and evaluation: 6 hours 4.Neuropsychological testing and evaluation: 12 hours (must document provider's qualifications to provide neuropsychological testing and evaluation services) 5.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; or b. a recipient's unusual clinical reaction to a medication 6.Assessment: 1 Integrated mental health and substance use intake assessment, OR 1 Mental health intake assessment every six months. 7.Short-term crisis intervention services: 22 hours 8.Screening and brief intervention services (SBIRT): 1 billable service / per day
Payment If a physician provides clinic services in a MHPC, the physician may submit a claim for payment: A.using the MHPC medical assistance provider identification number (payment subject to requirements and restrictions placed on MHPC) OR B.using 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.
Mental Health Intake Assessment A Mental Health Intake Assessment must be: 1. Conducted by a mental health professional clinician 2. Conducted upon admission to services & updated as new information becomes available 3.Conducted for the purpose of determining: a. recipients mental status, social and medical histories b. nature & severity of any mental health disorder c. complete multi-axial DSM diagnosis d. functional impairments e. treatment recommendations to form Tx Plan See 7 AAC for more information on documentation
Integrated Mental Health and Substance Use Intake Assessment 1.Documented in accordance with 7 AAC (Clinical Record) 2.Conducted by a mental health professional clinician: a.Upon admission to services & during the course of active treatment as necessary; b.Updated as new information becomes available 3.Conducted for the purpose of determining: 1.All the requirements of a Mental Health Intake Assessment 2.If the recipient has a substance use disorder 3.Nature & severity of any substance use disorder
Psychiatric 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 Practitioner working within the scope of their education, training, and experience has prescriptive authority enrolled under 7 AAC (c) as a dispensing provider
Psychiatric 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.
Psychological 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 capabilities the administration of standardized psychological tests the interpretation of findings.
Pharmacologic 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; and 3. monitoring the recipient's response to medication, including: a. documenting medication compliance; b. assessing & documenting side effects; c. evaluating & documenting effectiveness of the medication.
Psychotherapy The department will pay a MHPC for one or more of the following forms of psychotherapy, as coded in 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.
Psychotherapy 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.
Short-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: 1)the nature of the short-term crisis; 2)recipient's mental, emotional, and behavioral status; 3)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
Facilitation 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.
Screening & 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.
Screening & Brief Intervention (cont) Brief intervention is motivational discussion focused on: raising awareness of recipients substance use the potential harmful effects of substance use encouraging positive change Brief intervention may include: 1.Feedback 2.Goal setting 3.Coping strategies 4.Identification of risk factors 5.Information & advice
Screening & Brief Intervention (cont) MHPC must refer to appropriate program that will meet recipients needs if: 1.Screening reveals severe risk of substance use 2.Recipient is already substance use dependent 3.Recipient already received SBIRT and was unresponsive MHPC must document SBIRT in progress note SBIRT does not require assessment or Tx. Plan
Clinical Record Requirements The clinical record must include: An assessment A behavioral health treatment plan that meets the requirements of 7AAC ; A progress note for each day the service is provided, signed by the individual provider Must reflect all changes made to the recipients 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.
Treatment Plan Documented in accordance with 7 AAC (clinical record) Based on a behavioral health assessment Developed with the recipient or recipients 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 recipients parent or legal representative. Reviewed every days to determine need for continued care
Treatment Plan Documentation Recipients identifying information The date implementation of plan will begin Treatment goals that are directly related to the findings of the assessment The services and interventions that will be rendered to address the goals The name, signature, and credentials of the psychiatrist operating MHPC The signature of the recipient or the recipients parent or legal representative
Treatment Team As it applies to a MHPC, a behavioral health treatment team for a recipient under 18 must include: The recipient The recipients family members, including parents, guardians, and others involved in providing general oversight to the client A staff member from OCS if the recipient is in states custody A staff member from DJJ if the recipient is in their custody [Licensed] clinic staff A 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 institution Representative(s) from the recipient's educational system
Treatment Team Cont. All members of treatment team shall attend meetings of the team in person or by telephone and be involved in team decisions unless the clinical record documents that: 1.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-being 2.family members, school district employees, or government agency employees refuse to or are unable to participate after the provider's responsible efforts to encourage participation or 3.weather, illness, or other circumstances beyond the member's control prohibits that member from participating
Progress Notes 7AAC (8) Requires: Documented progress note for each service, each day service is provided Date service was provided Duration of the service expressed in service units or clock time Description of the active treatment provided (interventions) Treatment goals that the service targeted Description of the recipients progress toward treatment goals Name, signature, and credentials of the individual who rendered the service
Medicaid 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 Medicaid Medicare recipients with Dual Eligibility under both programs (i.e. disabled adults and adults over age 65) may be eligible under both Medicare and Medicaid Military and Veterans Benefits Private Health Insurance The recipients card/coupon will include Resource Code and/or Carrier Code to designate this coverage
Behavioral 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 recipients coupon or card issued by Division of Public Assistance (Medicaid coupon, Denali KidCare Card)
CAMA 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, and Has very limited coverage MHPC are not covered by CAMA CAMA coverage also includes limits the number of medications a person can receive in a month
Medicaid Program Policies & Claims Billing Procedures Manual Section I – Program Policies and Claims Billing Procedures for MHPC Services PART A – General Requirements PART B – Service Detail Sheets Section 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 Regulations Section II – Attachments and Remittances Attachments Supplemental documents Remittance Advice (RA) Reconciliation Adjustments/Voids Claim Inquiry Forms Order Section III – General Medical Assistance Information Claims Processing Overview Eligible Recipients for ALL programs General Program Regulations and Restrictions
Services New Codes/ ServicesChanging Services/ Codes CodeService Description H0031- HH Integrated Mental Health & Substance Use Intake Assessment Q3014 Facilitation of Telemedicine Psychotherapy, Family w/ out patient present S9484-U6 Short-Term Crisis Intervention (15 min) Screening, Brief Intervention & Referral for Treatment CodeDescriptionChange H0031Mental Health Assessment Units were based on time with 3 hr max Now based on 1 assessment, payable at flat rate 90849Psychotherapy Multi Family Group Change in Rate Rate was $ per hour Rate is now $ per hour
Service Authorization Annual Service Limits will switch from CALENDAR year to STATE FISCAL year All 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 change Requests to be made in correlation with requirement to review each case to determine need for continued treatment Requests will cover a maximum of 90 to 135 days of planned services and will be submitted approximately 3 to 4 times annually
How to find Alaska Medicaid Information using Affiliated Computer Services, Inc (ACS) Website start at the fiscal agents Alaska Medical Assistance page (http://www..medicaidalaska.com)http://www..medicaidalaska.com select Providers" located in the horizontal list at the top of the page select Billing Manuals" click on the boxed word Accept at the bottom of the page to indicate your agreement and acceptance of the copyright notice Claim form instructions CMS-1500 Professional Services (Set B is for use by outpatient behavioral health services providers) UB-04 Institutional Services (inpatient and residential psychiatric treatment center services Program Policies & Claims Billing Procedures Manuals for all covered services are listed alphabetically Mental Health Physician Clinic Other Service Providers (Physician, Advanced Nurse Practitioner, Federally Qualified Health Center, School Based Services) select Forms" Provider Enrollment Application forms Information Submission Agreements Service Authorization Forms select Updates Manual replacement pages select HIPAA" Companion Guides for all Electronic Transactions Tool kit, testing procedures, and other information for becoming an electronic submitter/receiver select Training" to view the training schedule, register for a class or view past materials select Contact Us for designated work units, staff, mailing addresses, etc.
Fiscal Agent Functions Processes all Medical Assistance claims, including technical support to accommodate electronic submission of claims and other transactions Provides customer service for providers and recipients Enrolls providers in Medical Assistance Provides Medical Assistance billing training to the provider community Publishes and distributes program policy & billing manuals Maintains website of information for providers Authorizes some services Performs First Level Provider Appeals Performs Intake for Recipient Fair Hearing Requests Generates and issues claim payments and tax information Performs Surveillance and Utilization Review (program integrity)
Claims Billing and Payment Tools & Support Program Policy & Billing Manuals Provider Training Provider Inquiry; Enhanced Provider Support Chandra Lewis in-state, toll free: (800) or Anchorage (907) Websites – Fiscal Agent (ACS) – DHSS/DBHwww.hss.state.ak.us/dbh – DHSS/DHCS Technical Support for Electronic Claims
Claims Filing Limits ALL 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.
Claims Editing All edits are three-digit codes with explanations of how the claim 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 an Explanation of Benefit (EOB) description page that lists all EOB codes and a brief description of each found within that specific Remittance Advice - Contact ACS, Inc. Provider Inquiry for clarification as needed
Integrated BH Regulations Training Claims Adjudication Process Flow
Provider Appeals REASONS to Request an Appeal Denied or reduced claims (180 days) Denied or reduced prior authorization (180 days) Disputed recovery of overpayment (60 days) Three Levels of Appeals First level appeals Second level appeals Commissioner level appeals
Recommend Billing Processes Read and maintain your billing manual Verify recipient eligibility Verify eligibility code Verify dates of eligibility Verify Third Party Liability Verify the services you are eligible to provide Verify procedure codes Obtain Service Authorization, if applicable File your license renewals and/or certification/permits timely (keep your enrollment current) Ensure completion of claim forms (reference provider manual) Document Third Party Liability payment on claim, if applicable Include attachments as required FILE TIMELY RECONCILE PAYMENTS Read and distribute RA messages Address problems/issues promptly Call Provider Inquiry with questions