(1) Definition. Psychotherapy is a face-to-face treatment for mental illnesses and behavioral disturbances, in which the clinician, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage growth and development. Insight oriented, behavior modifying and/or supportive psychotherapy refers to the development of insight of affective understanding, the use of behavior modification techniques, the use of supportive interactions, the use of cognitive discussion of reality, or any combination of these items to provide therapeutic change. Ongoing assessment of the member's status and response to treatment as well as psycho-educational intervention are appropriate components of individual therapy. The therapy must be goal directed, utilizing techniques appropriate to the service plan and the member's developmental and cognitive abilities.
(2) Interactive Complexity. Psychotherapy is considered to involve "interactive complexity" when there are communication factors during a visit that complicate delivery of the psychotherapy by the qualified practitioner. Sessions typically involve members who have other individuals legally responsible for their care (i.e. minors or adults with guardians); members who request others to be involved in their care during the session (i.e. adults accompanied by one or more participating family members or interpreter or language translator); or members that require involvement of other third parties (i.e. child welfare, juvenile justice, parole/probation officers, schools, etc.). Psychotherapy should only be reported as involving interactive complexity when at least one of the following communication factors is present:
(A) The need to manage maladaptive communication (i.e. related to high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicate delivery of care.
(B) Caregiver emotions/behavior that interfere with implementation of the service plan.
(C) Evidence/disclosure of a sentinel event and mandated report to a third party (i.e. abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants.
(D) Use of play equipment, physical devices, interpreter or translator to overcome barriers to therapeutic interaction with a patient who is not fluent in the same language or who has not developed or lost expressive or receptive language skills to use or understand typical language.
(3) Qualified practitioners. Psychotherapy must be provided by a Licensed Behavioral Health Professional (LBHP) or Licensure Candidate in a setting that protects and assures confidentiality.
(4) Limitations. A maximum of 4 units per day per member is compensable. A cumulative maximum of 8 units of individual psychotherapy and family psychotherapy per week per member is compensable. Except for psychotherapy involving interactive complexity as described in this Section, only the member and the qualified practitioner should be present during the session. Psychotherapy for a child younger than three must be medically necessary and meet established Child (0-36 months of Age) criteria as set forth in the Prior Authorization Manual. Limitations exclude outpatient behavioral health services provided in a therapeutic foster care setting.
(b) Group Psychotherapy.
(1) Definition. Group psychotherapy is a method of treating behavioral disorders using the interaction between the qualified practitioner and two or more individuals to promote positive emotional or behavioral change. The focus of the group must be directly related to the goals and objectives in the individual member's current service plan. This service does not include social or daily living skills development as described under Behavioral Health Rehabilitation Services.
(2) Group sizes. Group Psychotherapy is limited to a total of eight adult (18 and over) individuals except when the individuals are residents of an ICF/IID where the maximum group size is six. For all children under the age of 18, the total group size is limited to six.
(3) Multi-family and conjoint family therapy. Sessions are limited to a maximum of eight families/units. Billing is allowed once per family unit, though units may be divided amongst family members.
(4) Qualified practitioners. Group psychotherapy will be provided by an LBHP or Licensure Candidate. Group Psychotherapy must take place in a confidential setting limited to the qualified practitioner, an assistant or co-therapist, if desired, and the group psychotherapy participants.
(5) Limitations. A maximum of 6 units per day per member is compensable, not to exceed 12 units per week. Group Psychotherapy is not reimbursable for a child younger than three. Limitations exclude outpatient behavioral health services provided in a therapeutic foster care setting.
(c) Family Psychotherapy.
(1) Definition. Family Psychotherapy is a face-to-face psychotherapeutic interaction between a qualified practitioner and the member's family, guardian, and/or support system. It is typically inclusive of the identified member, but may be performed if indicated without the member's presence. When the member is an adult, his/her permission must be obtained in writing. Family psychotherapy must be provided for the direct benefit of the SoonerCare member to assist him/her in achieving his/her established treatment goals and objectives and it must take place in a confidential setting. This service may include the Evidence Based Practice titled Family Psychoeducation.
(2) Qualified practitioners. Family Psychotherapy must be provided by an LBHP or Licensure Candidate.
(3) Limitations. A maximum of 4 units per day per member/family unit is compensable. A cumulative maximum of 8 units of individual psychotherapy and family psychotherapy per week per member is compensable. The practitioner may not bill any time associated with note taking and/or medical record upkeep. The practitioner may only bill the time spent in direct face-to-face contact. Practitioner must comply with documentation requirements listed in OAC 317:30-5-248. Limitations exclude outpatient behavioral health services provided in a therapeutic foster care setting.
(d) Multi-Systemic Therapy (MST).
(1) Definition. MST intensive outpatient program services are limited to children within an Office of Juvenile Affairs (OJA) MST treatment program which provides an intensive, family and community-based treatment targeting specific BH disorders in children with SED who exhibit chronic, aggressive, antisocial, and/or substance abusing behaviors, and are at risk for out of home placement. Case loads are kept low due to the intensity of the services provided.
(2) Qualified professionals. Masters level professionals who work with a team that may include bachelor level staff.
(3) Documentation requirements. Providers must comply with documentation requirements in 317:30-5-248.
(4) Service limitations. Partial billing is not allowed, when only one service is provided in a day, providers should not bill for services performed for less than 8 minutes.
(e) Children/Adolescent Partial Hospitalization Program (PHP).
(1) Definition. Partial hospitalization services are services that (1) Are reasonable and necessary for the diagnosis or active treatment of the member's condition; (2) Are reasonably expected to improve the member's condition and functional level and to prevent relapse or hospitalization and (3) Include the following:
(A) Assessment, diagnostic and service plan services for mental illness and/or substance use disorders provided by LBHPs or Licensure Candidates.
(B) Individual/Group/Family (primary purpose is treatment of the member's condition) psychotherapies provided by LBHPs or Licensure Candidates.
(C) Substance use disorder specific services are provided by LBHPs or Licensure Candidates qualified to provide these services.
(D) Drugs and biologicals furnished for therapeutic purposes.
(E) Family counseling, the primary purpose of which is treatment of the member's condition.
(F) Behavioral health rehabilitation services to the extent the activities are closely and clearly related to the member's care and treatment, provided by a Certified Behavioral Health Case Manager II, Certified Alcohol and Drug Counselor (CADC), LBHP, or Licensure Candidate who meets the professional requirements listed in 317:30-5-240.3.
(G) Care Coordination of behavioral health services provided by certified behavioral health case managers.
(2) Qualified practitioners.
(A) All services in the PHP are provided by a clinical team, consisting of the following required professionals:
(i) A licensed physician;
(ii) Registered nurse; and
(iii) One or more of the licensed behavioral health professionals (LBHP) or Licensure Candidates listed in 30-5-240.3(a) and (b).
(B) The clinical team may also include a Certified Behavioral Health Case Manager.
(C) The service plan is directed under the supervision of a physician and the number of professionals and paraprofessionals required on the clinical team is dependent on the size of the program.
(3) Qualified providers. Provider agencies for PHP must be accredited by one of the national accrediting bodies; The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF) or The Council on Accreditation (COA) for partial hospitalization and enrolled in SoonerCare. Staff providing these services are employees or contractors of the enrolled agency.
(4) Limitations. Services are limited to children 0-20 only. Children under age 6 are not eligible for behavioral health rehabilitation services, unless a prior authorization for children ages 4 and 5 has been granted by OHCA or its designated agent based on a finding of medical necessity. Services must be offered at a minimum of 3 hours per day, 5 days per week. Therapeutic services are limited to 4 billable hours per day. PHP services are all inclusive with the exception of physician services and drugs that cannot be self-administered, those services are separately billable. Group size is limited to a maximum of 8 individuals as clinically appropriate given diagnostic and developmental functioning. Occupational, Physical and Speech therapy will be provided by the Independent School District (ISD). Academic instruction, meals, and transportation are not covered.
(A) Therapeutic Services are to include the following:
(i) Psychiatrist/physician face-to-face visit 2 times per month;
(ii) Crisis management services available 24 hours a day, 7 days a week;
(B) Psychotherapies to be provided a minimum of four (4) hours per week and include the following:
(i) Individual therapy - a minimum of 1 session per week;
(ii) Family therapy - a minimum of 1 session per week; and
(iii) Group therapy - a minimum of 2 sessions per week;
(C) Interchangeable services which include the following:
(i) Behavioral Health Case Management (face-to-face);
(ii) Behavioral health rehabilitation services/alcohol and other drug abuse education (except for children under age 6, unless a prior authorization has been granted for children ages 4 and 5);
(iii) Medication Training and Support; and
(iv) Expressive therapy.
(6) Documentation requirements. Documentation needs to specify active involvement of the member's family, caretakers, or significant others involved in the individual's treatment. A nursing health assessment must be completed within 24 hours of admission. A physical examination and medical history must be coordinated with the Primary Care Physician. Service plan updates are required every three (3) months or more frequently based on clinical need. Records must be documented according to Section OAC 317:30-5-248.
(7) Staffing requirements. Staffing requirements must consist of the following:
(A) RN trained and competent in the delivery of behavioral health services as evidenced by education and/or experience that is available onsite during program hours to provide necessary nursing care and/or psychiatric nursing care (1 RN at a minimum can be backed up by an LPN but an RN must always be onsite). Nursing staff administers medications, follows up with families on medication compliance, and restraint assessments.
(B) Medical director must be a licensed psychiatrist.
(C) A psychiatrist/physician must be available 24 hours a day, 7 days a week.
(f) Children/Adolescent Day Treatment Program.
(1) Definition. Day Treatment Programs are for the stabilization of children and adolescents with severe emotional and/or behavioral disturbances. Treatment is designed for children who have difficulty functioning in mainstream community settings such as classrooms, and who need a higher intensity of services than outpatient counseling provides. Treatment is time limited and includes therapeutically intensive clinical services geared towards reintegration to the home, school, and community.
(2) Qualified practitioners. All services in Day Treatment are provided by a team, which must be composed of one or more of the following participants: physician, registered nurse, licensed behavioral health professional (LBHP) or Licensure Candidate, a case manager, or other certified Behavioral Health/Substance Abuse paraprofessional staff. Services are directed by an LBHP or Licensure Candidate.
(3) Qualified providers. Provider agencies for Day Treatment must be accredited to provide Day Treatment services by one of the national accrediting bodies; The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF) or The Council on Accreditation (COA).
(4) Limitations. Services must be offered at a minimum of 4 days per week at least 3 hours per day. Behavioral Health Rehabilitation Group size is limited to a maximum of 8 individuals as clinically appropriate given diagnostic and developmental functioning. Children under age 6 are not eligible for behavioral health rehabilitation services, unless a prior authorization for children ages 4 and 5 has been granted by OHCA or its designated agent based on a finding of medical necessity.
(5) Service requirements. On-call crisis intervention services must be available 24 hours a day, 7 days a week (When members served have psychiatric needs, psychiatric services are available which include the availability of a psychiatrist 24 hours a day, 7 days a week. A psychiatrist can be available either on site or on call but must be available at all times). Day treatment program will provide assessment and diagnostic services and/or medication monitoring, when necessary.
(A) Treatment activities are to include the following every week:
(i) Family therapy at least one hour per week (additional hours of FT may be substituted for other day treatment services);
(ii) Group therapy at least two hours per week; and
(iii) Individual therapy at least one hour per week.
(B) Additional services are to include at least one of the following services per day:
(i) Medication training and support (nursing) once monthly if on medications;
(ii) Behavioral health rehabilitation services to include alcohol and other drug education if the child meets the criteria established in 317:30-5-241.3 and is clinically necessary and appropriate (except for children under age 6, unless a prior authorization has been granted for children ages 4 and 5);
(iii) Behavioral health case management as needed and part of weekly hours for member;
(iv) Occupational therapy as needed and part of weekly hours for member; and
(v) Expressive therapy as needed and part of weekly hours for the member.
(6) Documentation requirements. Service plans are required every three (3) months.