1. Psychosocial Rehabilitation (PSR)
Department of Medical Assistance Services
Psychosocial Rehabilitation (PSR)
H2017
2013 1

2. Department of Medical Assistance Services
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

3. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

4. PSR Service Definition
Department of Medical Assistance Services
PSR Service Definition
H2017 4

5. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

6. PSR Licensing Department of Medical Assistance Services H2017 6

7. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

8. PSR Staff Qualifications
Department of Medical Assistance Services
PSR Staff Qualifications
H2017 8

9. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

10. PSR Eligibility Criteria
Department of Medical Assistance Services
PSR Eligibility Criteria
H2017 10

11. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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:
who without these services would be unable to remain in the community OR
who meet at least two of the following criteria on a continuing or intermittent basis:
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

12. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
Psychosocial Rehabilitation - PSR
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;
Exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary; or
Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior. 12

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

14. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 14

15. PSR Required Activities
Department of Medical Assistance Services
PSR Required Activities
H2017 15

16. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 16

17. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 17

18. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 18

19. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 19

20. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 20

21. PSR Limitations and Supervision Requirements
Department of Medical Assistance Services
PSR Limitations and Supervision Requirements
H2017 21

22. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 22

23. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

24. PSR Units and Reimbursement
Department of Medical Assistance Services
PSR Units and Reimbursement
H2017 24

25. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 25

26. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

27. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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 30. 27

28. PSR Service Authorization
Department of Medical Assistance Services
PSR Service Authorization
H2017 28

29. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

30. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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 23294 30

31. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 31

32. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 32

33. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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. 33

34. Psychosocial Rehabilitation - PSR
Department of Medical Assistance Services
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

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