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H2017 www.dmas.virginia.gov 1 Department of Medical Assistance Services Psychosocial Rehabilitation (PSR) 2013.

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Presentation on theme: "H2017 www.dmas.virginia.gov 1 Department of Medical Assistance Services Psychosocial Rehabilitation (PSR) 2013."— Presentation transcript:

1 H Department of Medical Assistance Services Psychosocial Rehabilitation (PSR) 2013

2 2 Disclaimer These slides contain only highlights of the Virginia Medicaid Community Mental Health Rehabilitative Services Manual (CHMRS) and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations. *Please refer to the manual, available on the DMAS website portal, for in-depth information on Community Mental Health Rehabilitative Services criteria. Providers are responsible for adhering to related state and federal regulations. 2 Department of Medical Assistance Services

3 3 Psychosocial Rehabilitation - PSR Objectives of this Training Are: To define the criteria of Psychosocial Rehabilitation Services To identify staff qualifications; To clarify eligibility criteria; To identify required activities; To review limitations of the service; To outline service units and reimbursement; and To review service authorization requirements. 3 Department of Medical Assistance Services

4 H Department of Medical Assistance Services PSR Service Definition

5 5 Psychosocial Rehabilitation - PSR Psychosocial rehabilitation services are programs of two or more consecutive hours per day provided to groups of individuals in a non-residential setting. Services include assessment, education to teach the patient about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. 5 Department of Medical Assistance Services

6 H Department of Medical Assistance Services PSR Licensing

7 7 Psychosocial Rehabilitation - PSR Psychosocial Rehabilitation providers must have a Department of Behavioral Health and Developmental Services (DBHDS) license to provide Psychosocial Rehabilitation or Clubhouse Services. 7 Department of Medical Assistance Services

8 H Department of Medical Assistance Services PSR Staff Qualifications

9 9 Psychosocial Rehabilitation - PSR  Licensed Mental Health Professional (LMHP) or LMHP Supervisee or Resident  Qualified Mental Health Professional-Adult (QMHP-A)  Qualified Mental Health Professional-Eligible (QMHP-E)  Qualified Mental Health Paraprofessional (QPP or QMPP) * Qualification requirements may be found in Chapter II of the CMHRS Manual 9 Department of Medical Assistance Services

10 H Department of Medical Assistance Services PSR Eligibility Criteria

11 11 Psychosocial Rehabilitation - PSR  Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals: i.who without these services would be unable to remain in the community OR ii.who meet at least two of the following criteria on a continuing or intermittent basis: a.Experience difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of psychiatric hospitalization, homelessness, or isolation from social supports; 11 Department of Medical Assistance Services

12 12 Psychosocial Rehabilitation - PSR b.Experience difficulty in activities of daily living such as maintaining personal hygiene, preparing food and maintaining adequate nutrition, or managing finances to such a degree that health or safety is jeopardized; c.Exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary; or d.Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior Department of Medical Assistance Services

13 13 Psychosocial Rehabilitation - PSR  To receive Psychosocial Rehabilitative services, the individual must also meet one of the following criteria listed below. The individual must: 1.Have experienced long-term or repeated psychiatric hospitalization; or 2.Experience difficulty in activities of daily living and interpersonal skills; or 3.Have a limited or nonexistent support system; or 4.Are unable to function in the community without intensive intervention; or 5.Require long-term services to be maintained in the community 13 Department of Medical Assistance Services

14 14 Psychosocial Rehabilitation - PSR  If an individual has co-occurring mental health and substance use disorders, integrated treatment for both is allowed as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be clearly documented in the assessment, treatment plan and progress notes Department of Medical Assistance Services

15 H Department of Medical Assistance Services PSR Required Activities

16 16 Psychosocial Rehabilitation - PSR  Prior to treatment there must be a service-specific provider assessment which clearly documents the needs for services.  The service-specific provider assessment must be completed by a Licensed Mental Health Professional (LMHP), LMHP Supervisee or Resident or a Qualified Mental Health Professional-Adult (A) or QMHP-Eligible (E).  If the service-specific provider assessment is done by a QMHP-A or QMHP-E, it must be approved by an LMHP or LMHP Supervisee or Resident within 30 days of admission to services Department of Medical Assistance Services

17 17 Psychosocial Rehabilitation - PSR  Within 30 days of service initiation, the Individual Service Plan (ISP) must be completed by an LMHP, LMHP Supervisee or Resident or the QMHP-A or QMHP-E. The ISP must be cosigned by the individual.  Every three months, the LMHP, LMHP Supervisee or Resident, or the QMHP must review, modify as appropriate, and update the ISP Department of Medical Assistance Services

18 18 Psychosocial Rehabilitation - PSR  Services that continue for more than six months must be reviewed by an LMHP or LMHP Supervisee or Resident who must document the continued need for the service.  The ISP must be rewritten at least annually.  Services must be provided in accordance with the ISP.  Progress notes for psychosocial rehabilitation services are completed at least monthly. Notes must specifically describe the specific service that was provided. Notes must correlate with time billed Department of Medical Assistance Services

19 19 Psychosocial Rehabilitation - PSR  Services must perform education to teach the individual about mental illness and appropriate medication to avoid complications and relapse, provide opportunities to learn and use independent living skills, and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment.  The program must operate a minimum of two continuous hours in a 24-hour period.  The service provider must notify the primary care provider of the individual’s receipt of community mental health rehabilitative services Department of Medical Assistance Services

20 20 Psychosocial Rehabilitation - PSR  If case management is being provided, there must be coordination with the case management agency.  Time for field trips (off-site activities) is allowed if the goal is to provide an opportunity for supervised practice of socialization skills or therapeutic activities that are designed to increase the individual’s understanding of or ability to access community services Department of Medical Assistance Services

21 H Department of Medical Assistance Services PSR Limitations and Supervision Requirements

22 22 Psychosocial Rehabilitation - PSR  Paraprofessionals who do not meet the experience requirements listed in Chapter II of the Community Mental Health Rehabilitative Services (CMHRS) Manual may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and supervised by a QMHP-A, QMHP-E, LMHP, or LMHP Supervisee/Resident.  Supervision must include:  On-site observation of services  Face-to-face consultation with the paraprofessional (this may be group or individual)  A review of the individual’s progress towards achieving ISP goals and objectives and  Recommendations for ISP changes based on the individual’s status Department of Medical Assistance Services

23 23 Psychosocial Rehabilitation - PSR  Supervision, either group or individual, must occur and be documented in the clinical record monthly.  Staff Travel time is excluded  Vocational services are not reimbursable 23 Department of Medical Assistance Services

24 H Department of Medical Assistance Services PSR Units and Reimbursement

25 25 Psychosocial Rehabilitation - PSR  Psychosocial Rehabilitation Services (H2017) requires service authorization before any services (beyond the service-specific provider assessment) are reimbursed.  The service limit for service-specific provider assessments is 2 per provider per individual per fiscal year. This allows each provider to bill 2 service-specific provider assessments for each individual from July 1 – June 30 of every year.  The service-specific provider assessment code (H0032 with a U6 Modifier) must be billed before the service treatment (H2017) will pay in the Medicaid Management of Information System (MMIS) claims system Department of Medical Assistance Services

26 26 Psychosocial Rehabilitation - PSR  There is a maximum of 936 units that are allowed based on medical necessity per fiscal year.  One unit = 2 to 3.99 hours Two Units = 4 to 6.99 hours Three Units = 7+ hours  No more than three units may be billed per day 26 Department of Medical Assistance Services

27 27 Psychosocial Rehabilitation - PSR  A maximum of 936 units of PSR can be authorized annually. A claim edit is in place that will cut back payment or deny claims for services beyond the maximum number of units allowed.  Each July 1st all service limits will be set to zero.  A year is July 1 through June Department of Medical Assistance Services

28 H Department of Medical Assistance Services PSR Service Authorization

29 29 Psychosocial Rehabilitation - PSR KePRO is the DMAS contractor for Service Authorization (SA). For questions go to the SA website: DMAS.KePRO.org and click on Virginia Medicaid Phone: VAPAUTH or Fax: OKBYFAX or Web: 29 Department of Medical Assistance Services

30 30 Psychosocial Rehabilitation - PSR Submitting a request  The preferred method is through the Atrezzo® web-based program  Registration is required  Information on Atrezzo is available on the KePRO website, or call or (804) or mail to: »KePro »2810 North Parham Rd, Suite 305 »Henrico, Virginia Department of Medical Assistance Services

31 31 Psychosocial Rehabilitation - PSR  Initial review is required to be submitted to the SA contractor at admission.  Continued stay reviews are required to be submitted to the SA contractor prior to, however not more than 30 days before, the end of the current approval.  Clinical information is needed from the provider for review for medical necessity criteria. A checklist for both the initial and continued stay review is located at dmas.kepro.org.  Requests are authorized for up to 6 months at one time Department of Medical Assistance Services

32 32 Psychosocial Rehabilitation - PSR Requests should include:  A DSM diagnosis (V codes are not acceptable as stand alone diagnosis);  If there is a dual diagnosis of mental health and substance abuse, services must be integrated;  A description of symptoms/severity of illness; and  Demonstrate clinical necessity for the service with specific examples of how the individual meets each of the eligibility criteria Department of Medical Assistance Services

33 33 Psychosocial Rehabilitation - PSR  For continued stay submissions, examples of clinical necessity must document how the individual continues to meet the medical necessity (eligibility) criteria.  Use of the KePRO checklist helps to ensure that all required information is submitted and expedites review by reducing the need for requests to be pended for additional information Department of Medical Assistance Services

34 34 Psychosocial Rehabilitation - PSR Helpful Resources: 12VAC Emergency Regulations for Community Mental Health Services Virginia Medicaid Web Portal link DMAS Office of Behavioral Health: – Address DMAS Helpline: Richmond Area All other 34 Department of Medical Assistance Services

35 35 Psychosocial Rehabilitation - PSR Thank you for attending this training and helping to serve Virginia’s Medicaid Recipients Department of Medical Assistance Services


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