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Mental Health Physician Clinic

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Presentation on theme: "Mental Health Physician Clinic"— Presentation transcript:

1 Mental Health Physician Clinic
“Training on the Integrated Behavioral Health Services Regulations”

2 Resources

3 Resources DHSS/BH Website:
Training Materials Documents & Publications Forms FAQ’s Regulations Links

4 Regulations Clarification Process
Procedure for Providers to inquire about meaning or applicability of BH Services Regulations Mechanism for DHSS/BH to explain (FAQ) or interpret (Clarification) BH Services Regulations Method for compiling information leading to updates in Manual and potential revisions of BH Services Regulations The 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.

5 Regulations Clarification Cont.
Procedure: Provider completes & submits Form DHSS/BH staff researches question & develops recommended response DHSS/BH Executive Team reviews, edits and approves response DHSS/BH staff posts response as FAQ on website, and informs Provider; OR Publishes 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.

6 MHPC Requirements

7 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.”

8 Qualified Professional
Licensing Regulation Licensed Psychologist 7AAC Licensed Psychological Associate AS 08.86 Licensed Clinical Social Worker AS 08.95 Licensed Physician Assistant 7AAC Licensed Advanced Nurse Practitioner 7AAC Licensed Psychiatric Nursing Clinical Specialist AS 08.68 Licensed Marital & Family Therapist AS 08.63 Licensed Professional Counselor AS 08.29

9 MHPC Requirements: 7 AAC 135.030
Must be enrolled in Medicaid under 7 AAC Services are for treatment of a diagnosable mental health disorder; Services provided by psychiatrist or licensed professionals Psychiatrist 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 staff Services provided on MHPC premises or via telemedicine under 7 AAC AAC , unless the service: could not otherwise be provided; or 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.

10 MHPC 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 hours Approve all treatment plans in writing Review each case every days to determine the need for continued care Provide direct clinical consultation and supervision Assure services provided are medically necessary and clinically appropriate Assume professional responsibility for services provided. Notice the difference in the amount of time the psychiatrist is required to be on premise.

11 MHPC Services

12 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: Psychotherapy: 10 hours (any combination of individual, group, and family) Psychiatric assessments: 4 assessments Psychological testing and evaluation: 6 hours Neuropsychological 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; or b. a recipient's unusual clinical reaction to a medication Assessment: 1 Integrated mental health and substance use intake assessment, OR 1 Mental health intake assessment every six months. Short-term crisis intervention services: 22 hours Screening and brief intervention services (SBIRT): 1 billable service / per day

13 Payment If 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) OR 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.

14 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. recipient’s 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

15 Integrated 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 available Conducted for the purpose of determining: All the requirements of a Mental Health Intake Assessment If the recipient has a substance use disorder Nature & severity of any substance use disorder 7 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.

16 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

17 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.

18 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.

19 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.

20 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.

21 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.

22 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: 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

23 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.

24 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.”

25 Screening & Brief Intervention (con’t)
Brief intervention is motivational discussion focused on: raising awareness of recipient’s substance use the potential harmful effects of substance use encouraging positive change Brief intervention may include: Feedback Goal setting Coping strategies Identification of risk factors Information & advice

26 Screening & Brief Intervention (con’t)
MHPC must refer to appropriate program that will meet recipient’s needs if: Screening reveals severe risk of substance use Recipient is already substance use dependent Recipient already received SBIRT and was unresponsive MHPC must document SBIRT in progress note SBIRT does not require assessment or Tx. Plan

27 Documentation Requirements

28 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 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.

29 Treatment Plan Documented in accordance with 7 AAC (clinical record) Based on a behavioral health assessment Developed 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

30 Treatment Plan Documentation
Recipient’s 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 recipient’s parent or legal representative We 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.

31 Treatment Team As it applies to a MHPC, a behavioral health treatment team for a recipient under 18 must include: The recipient The recipient’s 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 state’s 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

32 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: 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 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 weather, illness, or other circumstances beyond the member's control prohibits that member from participating

33 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 recipient’s progress toward treatment goals Name, signature, and credentials of the individual who rendered the service

34 Medicaid Billing

35 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 Veteran’s Benefits Private Health Insurance The recipient’s card/coupon will include Resource Code and/or Carrier Code to designate this coverage

36 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 recipient’s coupon or card issued by Division of Public Assistance (Medicaid coupon, Denali KidCare Card)

37 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

38 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

39 Services New Codes/ Services Changing Services/ Codes Code
Service Description H0031-HH Integrated Mental Health & Substance Use Intake Assessment Q3014 Facilitation of Telemedicine 90846 Psychotherapy, Family w/ out patient present S9484-U6 Short-Term Crisis Intervention (15 min) 99408 Screening, Brief Intervention & Referral for Treatment Code Description Change H0031 Mental Health Assessment Units were based on time with 3 hr max Now based on 1 assessment, payable at flat rate 90849 Psychotherapy Multi Family Group Change in Rate Rate was $ per hour Rate is now $ per hour

40 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 SERVICE 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 year Requests 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.

41 How to find Alaska Medicaid Information using Affiliated Computer Services, Inc (ACS) Website
start at the fiscal agent’s Alaska Medical Assistance page ( 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.

42 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)

43 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/DBH – DHSS/DHCS Technical Support for Electronic Claims

44 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.

45 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

46 Claims Adjudication Process Flow
Integrated BH Regulations Training

47 Provider 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 Appeals First level appeals Second level appeals Commissioner level appeals

48 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 THIS SLIDE DEVELOPED TO SHOW YOU THE MAJOR COMPONENTS OF ACHIEVING SUCCESS IN BILLING CLAIMS ELIGIBILITY CLAIM FORM COMPLETION TIMELY FILING COMMUNICATION WITH FH *This is a great reference tool for you!!!! First thing is to verify eligibility


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