All outpatient behavioral health providers eligible for reimbursement under OAC 317:30-5-240 et seq. must be an accredited or Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) certified organization/agency in accordance with Section(s) 3-317, 3-323A, 3-306.1 or 3-415 of Title 43A of the Oklahoma Statutes and have a current contract on file with the Oklahoma Health Care Authority. Eligibility requirements for independent professionals (e.g., physicians and Licensed Behavioral Health Professionals), who provide outpatient behavioral health services and bill under their own national provider identification (NPI) number are covered under OAC 317:30-5-1 and OAC 317:30-5-275. Other outpatient ambulatory clinics (e.g. Federally Qualified Health Centers, Indian Health Clinics, school-based clinics) that offer outpatient behavioral health services are covered elsewhere in the agency rules.
The following words or terms, when used in this Part, shall have the following meaning, unless the context clearly indicates otherwise:
means one of the following:
(A) Accreditation Association for Ambulatory Health Care (AAAHC);
(B) American Osteopathic Association (AOA);
(C) Commission on Accreditation of Rehabilitation Facilities (CARF);
(D) Council on Accreditation of Services for Families and Children, Inc. (COA);
(E) The Joint Commission (TJC) formerly known as Joint Commission on Accreditation of Healthcare Organizations; or
(F) other OHCA approved accreditation.
means an individual 21 and over, unless otherwise specified.
means Alcohol and Other Drug.
means Alcohol and Other Drug Treatment Professional.
means the American Society of Addiction Medicine.
"ASAM Patient Placement Criteria (ASAM PPC)"
means the most
current edition of the American Society of Addiction Medicine's published criteria for admission to treatment, continued services, and discharge.
"Behavioral Health (BH) Services"
means a wide range of diagnostic, therapeutic, and rehabilitative services used in the treatment of mental illness, substance abuse, and co-occurring disorders.
means Behavioral Health Aides.
means the Oklahoma Department of Mental
Health and Substance Abuse Services (ODMHSAS).
means an individual younger than 21, unless otherwise specified.
"Client Assessment Record (CAR)"
means the standardized tool
recognized by OHCA and ODMHSAS to evaluate the functioning of the member.
means case management.
means Community Mental Health Centers who are state
operated or privately contracted providers of behavioral health services for adults with serious mental illnesses, and youth with serious emotional disturbances.
means the ability to recognize,
respect, and address the unique needs, worth, thoughts, communications, actions, customs, beliefs and values that reflect an individual's racial, ethnic, age group, religious, sexual orientation, and/or social group.
means the most current edition of the Diagnostic and
Statistical Manual of Mental Disorders published by the American Psychiatric Association.
means an Evidence Based Practice per the Substance
Abuse & Mental Health Services Administration (SAMHSA).
means the Medicaid Early and Periodic Screening,
Diagnostic and Treatment benefit for children. In addition to screening services, EPSDT also covers the diagnostic and treatment services necessary to ameliorate acute and chronic physical and mental health conditions.
means Facility Based Crisis Stabilization.
means Family Support Providers.
means Intermediate Care Facility for Individuals with
means an inpatient hospital facility or
Institution for Mental Disease (IMD).
means Institution for Mental Disease as per 42 CFR 435.1009 as a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. The regulations indicate that an institution is an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases. Title XIX of the Social Security Act provides that, except for individuals under age 21 receiving inpatient psychiatric care, Medicaid (Title XIX) does not cover services to IMD patients under 65 years of age [section 1905(a)(24)(B)].
"Level of Functioning Rating"
means a standardized mechanism to determine the intensity or level of services needed based upon the severity of the member's condition. The CAR level of function rating scale is the tool that links the clinical assessment to the appropriate level of Mental Health treatment. Either the Addiction Severity Index (ASI) or the Teen Addiction Severity Index (TASI), based on age, is the tool that links the clinical assessment to the appropriate level of Substance Abuse (SA) treatment.
means a Licensed Behavioral Health Professional.
means the EBP Multi-Systemic Therapy.
means Oklahoma Administrative Code, the publication authorized by 75 O.S. 256 known as The Oklahoma Administrative Code, or, prior to its publication, the compilation of codified rules authorized by 75 O.S. 256(A)(1)(a) and maintained in the Office of Administrative Rules.
means a specific statement of planned accomplishments or results that are specific, measurable, attainable, realistic, and time-limited.
means the Oklahoma Department of Mental Health and Substance Abuse Services.
"ODMHSAS contracted facilities"
means those providers that have a contract with the ODMHSAS to provide mental health or substance use disorder treatment services, and also contract directly with the Oklahoma Health Care Authority to provide Outpatient Behavioral Health Services.
means the Oklahoma Health Care Authority.
means the Office of Juvenile Affairs.
means the OHCA BH Provider Billing Manual.
means Residential Behavioral Management Services within a group home or therapeutic foster home.
means an ongoing process of discovery and/or rediscovery that must be self defined, individualized and may contain some, if not all, of the ten fundamental components of recovery as outlined by SAMHSA.
means Peer Recovery Support Specialist.
means the Substance Abuse and Mental Health Services Administration.
"Serious Emotional Disturbance (SED)"
means a condition experienced by persons from birth to 18 that show evidence of points of (A), (B) and (C) below:
(A) The disability must have persisted for six months and be expected to persist for a year or longer.
(B) A condition or serious emotional disturbance as defined by the most recently published version of the DSM or the International Classification of Disease (ICD) equivalent with the exception of DSM "V" codes, substance abuse, and developmental disorders which are excluded, unless they co-occur with another diagnosable serious emotional disturbance.
(C) The child must exhibit either i or ii below:
(i) Psychotic symptoms of a serious mental illness (e.g. Schizophrenia characterized by defective or lost contact with reality, often hallucinations or delusions); or
(ii) Experience difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. There is functional impairment in at least two of the following capacities (compared with expected developmental level):
(I) Impairment in self-care manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
(II) Impairment in community function manifested by a consistent lack of age appropriate behavioral controls, decision-making, judgment and value systems which result in potential involvement or involvement with the juvenile justice system.
(III) Impairment of social relationships manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults.
(IV) Impairment in family function manifested by a pattern of disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents, disregard for safety and welfare or self or others (e.g., fire setting, serious and chronic destructiveness, inability to conform to reasonable limitations and expectations which may result in removal from the family or its equivalent).
(V) Impairment in functioning at school manifested by the inability to pursue educational goals in a normal time frame (e.g., consistently failing grades, repeated truancy, expulsion, property damage or violence toward others).
"Serious Mental Illness (SMI)"
means a condition experienced by persons age 18 and over that show evidence of points of (A), (B) and (C) below:
(A) The disability must have persisted for six months and be expected to persist for a year or longer.
(B) A condition or serious mental illness as defined by the most recently published version of the DSM or the International Classification of Disease (ICD) equivalent with the exception of DSM "V" codes, substance abuse, and developmental disorders which are excluded, unless they co-occur with another diagnosable serious mental illness.
(C) The adult must exhibit either (i) or (ii) below:
(i) Psychotic symptoms of a serious mental illness (e.g. Schizophrenia characterized by defective or lost contact with reality, often hallucinations or delusions); or
(ii) Experience difficulties that substantially interfere with or limit an adult from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. There is functional impairment in at least two of the following capacities (compared with expected developmental level):
(I) Impairment in self-care manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
(II) Impairment in community function manifested by a consistent lack of appropriate behavioral controls, decision-making, judgment and value systems which result in potential involvement or involvement with the criminal justice system.
(III) Impairment of social relationships manifested by the consistent inability to develop and maintain satisfactory relationships with peers.
(IV) Impairment in family function manifested by a pattern of disruptive behavior exemplified by repeated and/or unprovoked violence, disregard for safety and welfare of self or others (e.g., fire setting, serious and chronic destructiveness, inability to conform to reasonable limitations and expectations).
(V) Impairment in functioning at school or work manifested by the inability to pursue educational or career goals.
means the recognition and responsiveness
to the presence of the effects of past and current traumatic experiences in the lives of members.
|317:30-5-240.2.||Provider participation standards|
(a) Accreditation and certification status. Any agency may participate as an OPBH provider if the agency is qualified to render a covered service and meets the OHCA requirements for provider participation.
(1) Private, Community-based Organizations must be accredited as a provider of outpatient behavioral health services from one of the accrediting bodies and be an incorporated organization governed by a board of directors or be certified by the certifying agency in accordance with Section(s) 3-317, 3-323A, 3-306.1, or 3-415 of Title 43A of the Oklahoma Statutes;
(2) State-operated programs under the direction of ODMHSAS must be accredited by one of the accrediting bodies or be certified by the certifying agency in accordance with Section(s) 3-317, 3-323A, 3-306.1 or 3-415 of Title 43A of the Oklahoma Statues;
(3) Freestanding Psychiatric Hospitals must be licensed and certified by the State Survey Agency as meeting Medicare psychiatric hospital standards and JCAHO accreditation;
(4) General Medical Surgical Hospitals must be appropriately licensed and certified by the State Survey Agency as meeting Medicare standards, including a JCAHO or AOA accreditation;
(5) Federally Qualified Health Centers/Community Health Centers facilities that qualify under OAC 317:30-5-660;
(6) Indian Health Services/Tribal Clinics/Urban Tribal Clinics facilities that qualify under Federal regulation;
(7) Rural Health Clinics facilities that qualify under OAC 317:30-5-355;
(8) Public Health Clinics and County Health Departments;
(9) Public School Systems.
(b) Certifications. In addition to the accreditation in paragraph (a) above or ODMHSAS certification in accordance with Section(s) 3-317, 3-323A, 3-306.1 or 3-415 of Title 43A of the Oklahoma Statutes, provider specific credentials are required for the following:
(1) Substance Abuse agencies (OAC 450:18-1-1);
(2) Evidence Based Best Practices but not limited to:
(A) Assertive Community Treatment (OAC 450:55-1-1);
(B) Multi-Systemic Therapy (Office of Juvenile Affairs); and
(C) Peer Support/Community Recovery Support;
(3) Systems of Care (OAC 340:75-16-46);
(4) Mobile and Facility-based Crisis Intervention (OAC 450:23-1-1);
(5) Case Management (OAC 450:50-1-1);
(6) RBMS in group homes (OAC 377:10-7) or foster care settings (OAC 340:75-8-4);
(7) Day Treatment - CARF, JCAHO, or COA will be required as of December 31, 2009; and
(8) Partial Hospitalization/Intensive Outpatient CARF, JCAHO, or COA will be required as of December 31, 2009.
(c) Provider enrollment and contracting.
(1) Organizations who have JCAHO, CARF, COA or AOA accreditation or ODMHSAS certification in accordance with Section(s) 3-317, 3-323A, 3-306.1 or 3-415 or Title 43A of the Oklahoma Statutes will supply the documentation from the accrediting body or certifying agency, along with other information as required for contracting purposes to the OHCA. The contract must include copies of all required state licenses, accreditation and certifications.
(2) If the contract is approved, a separate provider identification number for each outpatient behavioral health service site will be assigned. Each site operated by an outpatient behavioral health facility must have a separate provider contract and site-specific accreditation and/or certification as applicable. A site is defined as an office, clinic, or other business setting where outpatient behavioral health services are routinely performed. When services are rendered at the member's residence, a school, or when provided occasionally at an appropriate community based setting, a site is determined according to where the professional staff perform administrative duties and where the member's chart and other records are kept. Failure to obtain and utilize site specific provider numbers will result in disallowance of services.
(3) All behavioral health providers are required to have an individual contract with OHCA in order to receive SoonerCare reimbursement. This requirement includes outpatient behavioral health agencies and all individual rendering providers who work within an agency setting. Individual contracting rendering provider qualification requirements are set forth in OAC 317:30-3-2 and 317:30-5-240.3.
(d) Standards and criteria. Eligible organizations must meet each of the following:
(1) Have a well-developed plan for rehabilitation services designed to meet the recovery needs of the individuals served.
(2) Have a multi-disciplinary, professional team. This team must include all of the following:
(B) A Certified Behavioral Health Case Manager II (CM II) or CADC, if individual or group rehabilitative services for behavioral health disorders are provided, and the designated LBHP(s) on the team will not be providing rehabilitative services;
(C) An AODTP, if treatment of substance use disorders is provided;
(D) A registered nurse, advanced practice nurse, or physician assistant, with a current license to practice in the state in which the services are delivered if Medication Training and Support Service is provided;
(E) The member for whom the services will be provided, and parent/guardian for those under 18 years of age.
(F) A member treatment advocate if desired and signed off on by the member.
(3) Demonstrate the ability to provide each of the following outpatient behavioral health treatment services as described in OAC 317:30-5-241 et seq., as applicable to their program. Providers must provide proper referral and linkage to providers of needed services if their agency does not have appropriate services.
(A) Assessments and Service Plans;
(C) Behavioral Health Rehabilitation services;
(D) Crisis Intervention services;
(E) Support Services; and
(F) Day Treatment/Intensive Outpatient.
(4) Be available 24 hours a day, seven days a week, for Crisis Intervention services.
(5) Provide or have a plan for referral to physician and other behavioral health services necessary for the treatment of the behavioral disorders of the population served.
(6) Comply with all applicable Federal and State Regulations.
(7) Have appropriate written policy and procedures regarding confidentiality and protection of information and records, member grievances, member rights and responsibilities, and admission and discharge criteria, which shall be posted publicly and conspicuously.
(8) Demonstrate the ability to keep appropriate records and documentation of services performed.
(9) Maintain and furnish, upon request, a current report of fire and safety inspections of facilities clear of any deficiencies.
(10) Maintain and furnish, upon request, all required staff credentials including certified transcripts documenting required degrees.
(1) Allopathic or Osteopathic Physicians with a current license and board certification in psychiatry or board eligible in the state in which services are provided, or a current resident in psychiatry practicing as described in OAC 317:30-5-2.
(2) Practitioners with a license to practice in the state in which services are provided, issued by one of the licensing boards listed in (A) through (F). The exemptions from licensure under 59 '1353(4) (Supp. 2000) and (5), 59 '1903(C) and (D) (Supp. 2000), 59 '1925.3(B) (Supp. 2000) and (C), and 59 '1932(C) (Supp. 2000) and (D) do not apply to Outpatient Behavioral Health Services.
(B) Social Work (clinical specialty only),
(C) Professional Counselor,
(D) Marriage and Family Therapist,
(E) Behavioral Practitioner, or
(F) Alcohol and Drug Counselor.
(3) Advanced Practice Nurse (certified in a psychiatric mental health specialty), licensed as a registered nurse with a current certification of recognition from the board of nursing in the state in which services are provided.
(4) A Physician Assistant who is licensed in good standing in this state and has received specific training for and is experienced in performing mental health therapeutic, diagnostic, or counseling functions.
(5) Licensure candidates actively and regularly receiving board approved supervision, and extended supervision by a fully licensed clinician if board's supervision requirement is met but the individual is not yet licensed, to become licensed by one of the licensing boards listed in (2)(A) through (F) above. The supervising licensed professional responsible for the member's care must:
(A) staff the member's case with the candidate,
(B) be personally available, or ensure the availability of a fully licensed LBHP to the candidate for consultation while they are providing services,
(C) agree with the current plan for the member, and
(D) confirm that the service provided by the candidate was appropriate; and
(E) The member's medical record must show that the requirements for reimbursement were met and the licensed professional responsible for the member's care has reviewed, countersigned, and dated the service plan and any updates thereto so that it is documented that the licensed professional is responsible for the member's care.
(b) Certified Alcohol and Drug Counselors (CADC's). CADC's are defined as having a current certification as a CADC in the state in which services are provided.
(c) Multi-Systemic Therapy (MST) Provider. Masters level who work on a team established by OJA which may include Bachelor level staff.
(d) Peer Recovery Support Specialist (PRSS). The Peer Recovery Support Specialist must be certified by ODMHSAS pursuant to requirements found in OAC 450:53.
(e) Family Support and Training Provider (FSP). FSPs are defined as follows:
(1) Have a high school diploma or equivalent;
(2) be 21 years of age and have successful experience as a family member of a child or youth with serious emotional disturbance, or a minimum of 2 years experience working with children with serious emotional disturbance or be equivalently qualified by education in the human services field or a combination of work experience and education with one year of education substituting for one year of experience (preference is given to parents or care givers of child with SED);
(3) successful completion of ODMHSAS Family Support Training;
(4) pass background checks; and
(5) service plans must be overseen and approved by a LBHP; and
(6) must function under the general direction of a LBHP or systems of care team, with a LBHP available at all times to provide back up, support, and/or consultation.
(f) Behavioral Health Aide (BHA). BHAs are defined as follows:
(1) Behavioral Health Aides must have completed 60 hours or equivalent of college credit; or
(2) may substitute one year of relevant employment and/or responsibility in the care of children with complex emotional needs for up to two years of college experience; and
(3) must have successfully completed the specialized training and education curriculum provided by the ODMHSAS; and
(4) must be supervised by a bachelor's level individual with a minimum of two years case management or care coordination experience; and
(5) service plans must be overseen and approved by a LBHP; and
(6) must function under the general direction of a LBHP and/or systems of care team, with a LBHP available at all times to provide back up, support, and/or consultation.
(a) Outpatient behavioral health services are covered for adults and children as set forth in this Section when provided in accordance with a documented individualized service plan, developed to treat the identified behavioral health and/or substance use disorder(s), unless specified otherwise.
(b) All services are to be for the goal of improvement of functioning, independence, or well-being of the member. The services and service plans are to be recovery focused, trauma and co-occurring specific. The member must be able to actively participate in the treatment. Active participation means that the member must have sufficient cognitive abilities, communication skills, and short-term memory to derive a reasonable benefit from the treatment.
(c) In order to be reimbursed for services, providers must submit a completed Customer Data Core (CDC) to OHCA or its designated agent. The CDC must be reviewed, updated and resubmitted by the provider every six months. Reimbursement is made only for services provided while a current CDC is on file with OHCA or its designated agent. For further information and instructions regarding the CDC, refer to the Behavioral Health Provider Manual.
(d) All outpatient BH services must be provided following established medical necessity criteria. Some outpatient behavioral health services may require authorization. For information regarding services requiring authorization and the process for obtaining them, refer to the Behavioral Health Provider Manual. Authorization of services is not a guarantee of payment. The provider is responsible for ensuring that the eligibility, medical necessity, procedural, coding, claims submission, and all other state and federal requirements are met. OHCA does retain the final administrative review over both authorization and review of services as required by 42 CFR 431.10.
(e) Services to nursing facility residents. Reimbursement is not allowed for outpatient behavioral health services provided to members residing in a nursing facility. Provision of these services is the responsibility of the nursing facility and reimbursement is included within the rate paid to the nursing facility for the member's care.
|317:30-5-241.1.||Screening, assessment and service plan|
All providers must comply with the requirements as set forth in this Section.
(A) Definition. Screening is for the purpose of determining whether the member meets basic medical necessity and need for further BH assessment and possible treatment services.
(B) Qualified professional. Screenings can be performed by any credentialed staff members as listed under OAC 317:30-5-240.3.
(C) Target population. This service is compensable only on behalf of a member who is under a PACT program.
(A) Definition. Gathering and assessment of historical and current bio-psycho-social information which includes face-to-face contact with the person and/or the person's family or other informants, or group of persons resulting in a written summary report, diagnosis and recommendations. All agencies must assess the medical necessity of each individual to determine the appropriate level of care.
(B) Qualified professional. This service is performed by an LBHP.
(C) Time requirements. The minimum face-to-face time spent in assessment session(s) with the member and others as identified previously in paragraph (1) of this subsection for a low complexity Behavioral Health Assessment by a Non-Physician is one and one half hours. For a moderate complexity, it is two hours or more.
(D) Target population and limitations. The Behavioral Health Assessment by a Non-Physician, moderate complexity, is compensable on behalf of a member who is seeking services for the first time from the contracted agency. This service is not compensable if the member has previously received or is currently receiving services from the agency, unless there has been a gap in service of more than six months and it has been more than one year since the previous assessment.
(E) Documentation requirements. The assessment must include all elements and tools required by the OHCA. In the case of children under the age of 18, it is performed with the direct, active face-to-face participation of the parent or guardian. The child's level of participation is based on age, developmental and clinical appropriateness. The assessment must include at least one DSM diagnosis from the most recent DSM edition. The assessment must contain but is not limited to the following:
(i) Date, to include month, day and year of the assessment session(s);
(ii) Source of information;
(iii) Member's first name, middle initial and last name;
(v) Birth Date;
(vi) Home address;
(vii) Telephone number;
(viii) Referral source;
(ix) Reason for referral;
(x) Person to be notified in case of emergency;
(xi) Presenting reason for seeking services;
(xii) Start and stop time for each unit billed;
(xiii) Signature of parent of guardian participating in face-to-face assessment. Signature required for members over the age of 14;
(xiv) Bio-Psychosocial information which must include:
(I) Identification of the member's strengths, needs, abilities and preferences;
(II) History of the presenting problem;
(III) Previous psychiatric treatment history, include treatment for psychiatric; substance abuse; drug and alcohol addiction; and other addictions;
(IV) Health history and current biomedical conditions and complications;
(V) Alcohol, Drug, and/or other addictions history;
(VI) Trauma, abuse, neglect, violence, and/or sexual assault history of self and/or others, include Department of Human Services involvement;
(VII) Family and social history, include MH, SA, Addictions, Trauma/Abuse/Neglect;
(VIII) Educational attainment, difficulties and history;
(IX) Cultural and religious orientation;
(X) Vocational, occupational and military history;
(XI) Sexual history, including HIV, AIDS, and STD at-risk behaviors;
(XII) Marital or significant other relationship history;
(XIII) Recreation and leisure history;
(XIV) Legal or criminal record, including the identification of key contacts, (e.g., attorneys, probation officers, etc.);
(XV) Present living arrangements;
(XVI) Economic resources;
(XVII) Current support system including peer and other recovery supports.
(xv) Mental status and Level of Functioning information, including questions regarding:
(I) Physical presentation, such as general appearance, motor activity, attention and alertness, etc.;
(II) Affective process, such as mood, affect, manner and attitude, etc.;
(III) Cognitive process, such as intellectual ability, social-adaptive behavior, thought processes, thought content, and memory, etc.; and
(IV) Full DSM diagnosis.
(xvi) Pharmaceutical information to include the following for both current and past medications;
(I) Name of medication;
(II) Strength and dosage of medication;
(III) Length of time on the medication; and
(IV) Benefit(s) and side effects of medication.
(xvii) LBHP's interpretation of findings and diagnosis;
(xviii) Signature and credentials of LBHP who performed the face-to-face behavioral assessment;
(xix) Client Data Core Elements reported into designated OHCA representative.
(3) Behavioral Health Services Plan Development.
(A) Definition. The Behavioral Health Service Plan is developed based on information obtained in the assessment and includes the evaluation of all pertinent information by the practitioners and the member. It includes a discharge plan. It is a process whereby an individualized plan is developed that addresses the member's strengths, functional assets, weaknesses or liabilities, treatment goals, objectives and methodologies that are specific and time limited, and defines the services to be performed by the practitioners and others who comprise the treatment team. Behavioral Health Service Plan Development is performed with the direct active participation of the member and a member support person or advocate if requested by the member. In the case of children under the age of 18, it is performed with the participation of the parent or guardian and the child as age and developmentally appropriate, and must address school and educational concerns and assisting the family in caring for the child in the least restrictive level of care. For adults, it is focused on recovery and achieving maximum community interaction and involvement including goals for employment, independent living, volunteer work, or training. A Service Plan Development, Low Complexity is required every 6 months and must include an update to the bio-psychosocial assessment and re-evaluation of diagnosis.
(B) Qualified professional. This service is performed by an LBHP.
(C) Time requirements. Service Plan updates must be conducted face-to-face and are required every six months during active treatment. Updates can be conducted whenever it is clinically needed as determined by the LBHP and member.
(D) Documentation requirements. Comprehensive and integrated service plan content must address the following:
(i) member strengths, needs, abilities, and preferences(SNAP);
(ii) identified presenting challenges, problems, needs and diagnosis;
(iii) specific goals for the member;
(iv) objectives that are specific, attainable, realistic, and time-limited;
(v) each type of service and estimated frequency to be received;
(vi) the practitioner(s) name and credentials that will be providing and responsible for each service;
(vii) any needed referrals for service;
(viii) specific discharge criteria;
(ix) description of the member's involvement in, and responses to, the service plan, and his/her signature and date;
(x) service plans are not valid until all signatures are present (signatures are required from the member (if 14 or over), the parent/guardian (if younger than 18 or otherwise applicable), and the primary LBHP; and
(xi) all changes in service plan must be documented in a service plan update (low complexity) or within the service plan until time for the update (low complexity). Any changes to the existing service plan must be signed and dated by the member (if 14 or over), the parent/guardian (if younger than 18 or otherwise applicable), and the lead LBHP.
(xii) Updates to goals, objectives, service provider, services, and service frequency, must be documented within the service plan until the six month review/update is due.
(xiii) Service plan updates must address the following:
(I) update to the bio-psychosocial assessment, re-evaluation of diagnosis service plan goals and/ or objectives;
(II) progress, or lack of, on previous service plan goals and/or objectives;
(III) a statement documenting a review of the current service plan and an explanation if no changes are to be made to the service plan;
(IV) change in goals and/or objectives (including target dates) based upon member's progress or identification of new need, challenges and problems;
(V) change in frequency and/or type of services provided;
(VI) change in practitioner(s) who will be responsible for providing services on the plan;
(VII) change in discharge criteria;
(VIII) description of the member's involvement in, and responses to, the service plan, and his/her signature and date; and
(IX) service plans are not valid until all signatures are present. The required signatures are: from the member (if 14 or over), the parent/guardian (if younger than 18 or otherwise applicable), and the primary LBHP.
(E) Service limitations:
(i) Behavioral Health Service Plan Development, Moderate complexity (i.e., pre-admission procedure code group) are limited to 1 per member, per provider, unless more than a year has passed between services, then another one can be requested and may be authorized by OHCA or its designated agent.
(ii) Behavioral Health Service Plan Development, Low Complexity: Service Plan updates are required every six months during active treatment. Updates can be conducted whenever needed as determined by the provider and member. The date of service is when the service plan is complete and the date the last required signature is obtained. Services should always be age, developmentally, and clinically appropriate.
(4) Assessment/Evaluation testing.
(A) Definition. Assessment/Evaluation testing is provided by a clinician utilizing tests selected from currently accepted assessment test batteries. Test results must be reflected in the Service Plan. The medical record must clearly document the need for the testing and what the testing is expected to achieve.
(B) Qualified professionals. Assessment/Evaluation testing will be provided by a psychologist, certified psychometrist, psychological technician of a psychologist or a LBHP. For assessments conducted in a school setting, the Oklahoma State Department of Education requires that a licensed supervisor sign the assessment. Each qualified professional must have a current contract with the Oklahoma Health Care Authority.
(C) Documentation requirements. All psychological services must be reflected by documentation in the member's record. All assessment, testing, and treatment services/units billed must include the following:
(ii) start and stop time for each session/unit billed and physical location where service was provided;
(iii) signature of the provider;
(iv) credentials of provider;
(v) specific problem(s), goals and/or objectives addressed;
(vi) methods used to address problem(s), goals and objectives;
(vii) progress made toward goals and objectives;
(viii) patient response to the session or intervention; and
(ix) any new problem(s), goals and/or objectives identified during the session.
(D) Service Limitations. Testing 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 Behavioral Health Provider Manual. Evaluation and testing is clinically appropriate and allowable when an accurate diagnosis and determination of treatment needs is needed. Eight hours/units of testing per patient over the age of two, per provider is allowed every 12 months. There may be instances when further testing is appropriate based on established medical necessity criteria found in the Behavioral Health Provider Manual. Justification for additional testing beyond allowed amount as specified in this section must be clearly explained and documented in the medical record. Testing units must be billed on the date the actual testing, interpretation, scoring, and reporting are performed. A maximum of 12 hours of therapy and testing, per day per rendering provider are allowed. A child who is being treated in an acute inpatient setting can receive separate psychological services by a physician or psychologist as the inpatient per diem is for "non-physician" services only. A child receiving Residential level treatment in either a therapeutic foster care home, or group home may not receive additional individual, group or family counseling or psychological testing unless allowed by the OHCA or its designated agent. Psychologists employed in State and Federal Agencies, who are not permitted to engage in private practice, cannot be reimbursed for services as an individually contracted provider. For assessment conducted in a school setting the Oklahoma State Department of Education requires that a licensed supervisor sign the assessment. Individuals who qualify for Part B of Medicare: Payment is made utilizing the SoonerCare allowable for comparable services. Payment is made to physicians, LBHPs or psychologists with a license to practice in the state where the services is performed or to practitioners who have completed education requirements and are under current board approved supervision to become licensed.
(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 LBHP. 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 professionals. Psychotherapy must be provided by a Licensed Behavioral Health Professional (LBHP) in a setting that protects and assures confidentiality.
(4) Limitations. A maximum of 6 units per day per member is compensable. Except for psychotherapy involving interactive complexity as described in this Section, only the member and the Licensed Behavioral Health Professional (LBHP) 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.
(b) Group Psychotherapy.
(1) Definition. Group psychotherapy is a method of treating behavioral disorders using the interaction between the LBHP 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 professionals. Group psychotherapy will be provided by a LBHP. Group Psychotherapy must take place in a confidential setting limited to the LBHP, an assistant or co-therapist, if desired, and the group psychotherapy participants.
(5) Limitations. A maximum of 12 units per day per member is compensable. Group 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.
(c) Family Psychotherapy.
(1) Definition. Family Psychotherapy is a face-to-face psychotherapeutic interaction between a LBHP 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 professionals. Family Psychotherapy must be provided by a LBHP.
(3) Limitations. A maximum of 12 units per day per member/family unit is compensable. The provider may not bill any time associated with note taking and/or medical record upkeep. The provider may only bill the time spent in direct face-to-face contact. Provider must comply with documentation requirements listed in OAC 317:30-5-248.
(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.
(B) Individual/Group/Family (primary purpose is treatment of the member's condition) psychotherapies provided by LBHPs.
(C) Substance use disorder specific services are provided by LBHPs 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)or LBHP 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 professionals.
(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) listed in 30-5-240.3(a).
(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 professionals. 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), a case manager, or other certified Behavioral Health/Substance Abuse paraprofessional staff. Services are directed by an LBHP.
(3) Qualified providers. Provider agencies for Day Treatment 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).
(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.
|317:30-5-241.3.||Behavioral Health Rehabilitation (BHR) services|
(b) Psychosocial Rehabilitation (PSR).
(1) Definition. PSR services are face-to-face Behavioral Health Rehabilitation services which are necessary to improve the member's ability to function in the community. They are performed to improve the skills and abilities of members to live interdependently in the community, improve self-care and social skills, and promote lifestyle change and recovery practices. Rehabilitation services may be provided individually or in group sessions, and they take the format of curriculum based education and skills training.
(2) Clinical restrictions. This service is generally performed with only the members and the qualified provider, but may include a member and the member's family/support system when providing educational services from a curriculum that focuses on the member's diagnosis, symptom management, and recovery. A member who at the time of service is not able to cognitively benefit from the treatment due to active hallucinations, substance abuse, or other impairments is not suitable for this service. Family involvement is allowed for support of the member and education regarding his/her recovery, but does not constitute family therapy, which requires a licensed provider.
(3) Qualified providers. A Certified Behavioral Health Case Manager II (CM II), CADC, and LBHP may perform PSR, following development of a service plan and treatment curriculum approved by a LBHP. The CM II and CADC must have immediate access to a fully licensed LBHP who can provide clinical oversight and collaborate with the qualified PSR provider in the provision of services. A minimum of one monthly face-to-face consultation with a fully licensed LBHP is required for PSR providers. A minimum of one face-to-face consultation per week with a LBHP is required for PSR providers regularly rendering services away from the outpatient behavioral health agency site.
(4) Group sizes. The maximum staffing ratio is fourteen members for each qualified provider for adults and eight to one for children under the age of eighteen.
(A) Transportation. Travel time to and from PSR treatment is not compensable. Group PSR services do not qualify for the OHCA transportation program, but OHCA will arrange for transportation for those who require specialized transportation equipment.
(B) Time. Breaks, lunchtime and times when the member is unable or unwilling to participate are not compensable and must be deducted from the overall billed time.
(C) Location. In order to develop and improve the member's community and interpersonal functioning and self care abilities, PSR services may take place in settings away from the outpatient behavioral health agency site as long as the setting protects and assures confidentiality. When this occurs, the qualified provider must be present and interacting, teaching, or supporting the defined learning objectives of the member for the entire claimed time.
(D) Eligibility for PSR services. All PSR services require prior authorization and must meet established medical necessity criteria.
(i)Adults. PSR services for adults are limited to members who have a history of psychiatric hospitalization or admissions to crisis centers, have been determined disabled by the SSA for mental health reasons, are residing in residential care facilities or are receiving services through a specialty court program.
(ii) Children. PSR services for children are limited to members who have a history of psychiatric hospitalization or admissions to crisis centers; have been determined disabled by the SSA for mental health reasons; have a current Individual Education Plan (IEP) or 504 Plan for emotional disturbance; or have been evaluated by a school psychologist, licensed psychologist or psychiatrist and determined to be "at risk" as outlined in the Prior Authorization Manual.
(iii) The following members are not eligible for PSR services:
(I) Residents of ICF/IID facilities, unless authorized by OHCA or its designated agent;
(II) children under age 6, unless a prior authorization for children ages 4 and 5 has been granted by OHCA or its designated agent based on the criteria in (5)(D)(ii) above as well as a finding of medical necessity;
(III) children receiving RBMS in a group home or therapeutic foster home, unless authorized by OHCA or its designated agent;
(IV) inmates of public institutions;
(V) members residing in inpatient hospitals or IMDs; and
(VI) members residing in nursing facilities.
(E) Billing limits. PSR services are time-limited services designed to be provided over the briefest and most effective period possible and as adjunct (enhancing) interventions to compliment more intensive behavioral health therapies. Service limits are based on the member's needs according to the CAR or other approved tool, the requested placement based on the level of functioning rating, medical necessity, and best practice. Service limitations are designed to help prevent rehabilitation diminishing return by remaining within reasonable age and developmentally appropriate daily limits. PSR services authorized under this Section are separate and distinct from, but should not duplicate the structured services required for children residing in group home or therapeutic foster care settings, or receiving services in Day Treatment or Partial Hospitalization Programs. Children under an ODMHSAS Systems of Care program and adults residing in residential care facilities may be prior authorized additional units as part of an intensive transition period. PSR is billed in unit increments of 15 minutes with the following limits:
(i) Group PSR. The maximum is 24 units per day for adults and 16 units per day for children.
(ii) Individual PSR. The maximum is six units per day.
(iii) Per-Member service levels and limits. Unless otherwise specified, group and/or individual PSR services provided in combination may not exceed the monthly limits established in the individual's prior authorization. Limits on PSR services are established based on the level for which the member has been approved.
(iv) EPSDT. Pursuant to OAC 317:30-3-65 et seq., billing limits may be exceeded or may not apply if documentation demonstrates that the requested services are medically necessary and are needed to correct or ameliorate defects, physical or behavioral illnesses or conditions discovered through a screening tool approved by OHCA or its designated agent. The OHCA has produced forms for documenting an EPSDT child health checkup screening which the provider can access on the OHCA website.
(F) Progress Notes. In accordance with OAC 317:30-5-241.1, the behavioral health service plan developed by the LBHP must include the member's strengths, functional assets, weaknesses or liabilities, treatment goals, objectives and methodologies that are specific and time-limited, and defines the services to be performed by the practitioners and others who comprise the treatment team. When PSR services are prescribed, the plan must address objectives that are specific, attainable, realistic, and time-limited. The plan must include the appropriate treatment coordination to achieve the maximum reduction of the mental and/or behavioral health disability and to restore the member to their best possible functional level. Progress notes for PSR day programs may be in the form of daily summary or weekly summary notes. Progress notes for all Behavioral Health Rehabilitation services must include the following:
(i) Curriculum sessions attended each day and/or dates attending during the week;
(ii) Start and stop times for each day attended and the physical location in which the service was rendered;
(iii) Specific goal(s) and objectives addressed during the week;
(iv) Type of Skills Training provided each day and/or during the week including the specific curriculum used with member;
(v) Member satisfaction with staff intervention(s);
(vi) Progress, or barrier to, made towards goals, objectives;
(vii) New goal(s) or objective(s) identified;
(viii) Signature of the lead qualified provider; and
(ix) Credentials of the lead qualified provider;
(G) Additional documentation requirements.
(i) a list/log/sign in sheet of participants for each Group rehabilitative session and facilitating qualified provider must be maintained; and
(ii) Documentation of ongoing consultation and/or collaboration with a LBHP related to the provision of PSR services.
(H) Non-Covered Services. The following services are not considered BHR and are not reimbursable:
(i) Room and board;
(ii) educational costs;
(iii) supported employment; and
(c) Outpatient Substance Abuse Rehabilitation Services.
(1) Definition. Covered outpatient substance abuse rehabilitation services are provided in non-residential settings in regularly scheduled sessions intended for individuals not requiring a more intensive level of care or those who require continuing services following more intensive treatment regimes. The purpose of substance abuse rehabilitation services is to begin, maintain, and/or enhance recovery from alcoholism, problem drinking, drug abuse, drug dependency addiction or nicotine use and addiction. Rehabilitation services may be provided individually or in group sessions, and they take the format of curriculum based education and skills training.
(2) Limitations. Group sessions may not be provided in the home.
(3) Eligibility. Members eligible for substance abuse rehabilitation services must meet the criteria for ASAM PCC Treatment Level 1, Outpatient Treatment.
(4) Qualified providers. CM II, CADC or LBHP.
(5) Billing limits. Group rehabilitation is limited to two (2) hours per session. Group and/or individual outpatient substance abuse rehabilitation services provided in combination may not exceed the monthly limits established in the individual's prior authorization. Limits on services are established based on the level for which the member has been approved. There are no limits on substance abuse rehabilitation services for individuals determined to be Level 4.
(6) Documentation requirements. Documentation requirements are the same as for PSR services as set forth in 30-5-241.3(b)(5)(F).
(d) Medication training and support.
(1) Definition. Medication Training and Support is a documented review and educational session by a registered nurse, advanced practice nurse, or physician assistant focusing on a member's response to medication and compliance with the medication regimen. The review must include an assessment of medication compliance and medication side effects. Vital signs must be taken including pulse, blood pressure and respiration and documented within the medical or clinical record. A physician is not required to be present, but must be available for consult. Medication Training and Support is designed to maintain the member on the appropriate level of the least intrusive medications, encourage normalization and prevent hospitalization.
(A) Medication Training and Support may not be billed for SoonerCare members who reside in ICF/IID facilities.
(B) Two units are allowed per month per patient.
(C) Medication Training & Support is not allowed to be billed on the same day as an evaluation and management (E/M) service provided by a psychiatrist.
(3) Qualified professionals. Must be provided by a licensed registered nurse, an advanced practice nurse, or a physician assistant as a direct service under the supervision of a physician.
(4) Documentation requirements. Medication Training and Support documented review must focus on:
(A) a member's response to medication;
(B) compliance with the medication regimen;
(C) medication benefits and side effects;
(D) vital signs, which include pulse, blood pressure and respiration; and
(E) documented within the progress notes/medication record.
(a) Onsite and Mobile Crisis Intervention Services (CIS).
(1) Definition. Crisis Intervention Services are face-to-face services for the purpose of responding to acute behavioral or emotional dysfunction as evidenced by psychotic, suicidal, homicidal severe psychiatric distress, and/or danger of AOD relapse. The crisis situation including the symptoms exhibited and the resulting intervention or recommendations must be clearly documented.
(2) Limitations. Crisis Intervention Services are not compensable for SoonerCare members who reside in ICF/MR facilities, or who receive RBMS in a group home or Therapeutic Foster Home. CIS is also not compensable for members who experience acute behavioral or emotional dysfunction while in attendance for other behavioral health services, unless there is a documented attempt of placement in a higher level of care. The maximum is eight units per month; established mobile crisis response teams can bill a maximum of sixteen units per month, and 40 units each 12 months per member.
(3) Qualified professionals. Services must be provided by a LBHP.
(b) Facility Based Crisis Stabilization (FBCS). FBCS services are emergency psychiatric and substance abuse services aimed at resolving crisis situations. The services provided are emergency stabilization, which includes a protected environment, chemotherapy, detoxification, individual and group treatment, and medical assessment.
(1) Qualified professionals. FBCS services are provided under the supervision of a physician aided by a licensed nurse, and also include LBHPs for the provision of group and individual treatments. A physician must be available. This service is limited to providers who contract with or are operated by the ODMHSAS to provide this service within the overall behavioral health service delivery system.
(2) Limitations. The unit of service is per hour. Providers of this service must meet the requirements delineated in the OAC 450:23. Documentation of records must comply with OAC 317:30-5-248.
|[Revised 09-12-14] |
(a) Program of Assertive Community Treatment (PACT) Services.
(1) Definition. PACT is provided by an interdisciplinary team that ensures service availability 24 hours a day, seven days a week and is prepared to carry out a full range of treatment functions wherever and whenever needed. An individual is referred to the PACT team service when it has been determined that his/her needs are so pervasive and/or unpredictable that it is unlikely that they can be met effectively by other combinations of available community services, or in circumstances where other levels of outpatient care have not been successful to sustain stability in the community.
(2) Target population. Individuals 18 years of age or older with serious and persistent mental illness and co-occurring disorders. PACT services are those services delivered within an assertive community-based approach to provide treatment, rehabilitation, and essential behavioral health supports on a continuous basis to individuals 18 years of age or older with serious mental illness with a self-contained multi-disciplinary team. The team must use an integrated service approach to merge essential clinical and rehabilitative functions and staff expertise. This level of service is to be provided only for persons most clearly in need of intensive ongoing services.
(3) Qualified professionals. Providers of PACT services are specific teams within an established organization and must be operated by or contracted with and certified by the ODMHSAS in accordance with 43A O.S. 319 and OAC 450:55. The team leader must be an LBHP.
(4) Limitations. PACT services are billable in 15 minute units. A maximum of 105 hours per member per year in the aggregate is allowed. All PACT compensable SoonerCare services are required to be face-to-face. The following services are separately billable: Case management, facility-based crisis stabilization, physician and medical services.
(5) Service requirements. PACT services must include the following:
(A) PACT assessments (initial and comprehensive);
(i) Initial assessment- is the initial evaluation of the member based upon available information, including self-reports, reports of family members and other significant parties, and written summaries from other agencies, including police, court, and outpatient and inpatient facilities, where applicable, culminating in a comprehensive initial assessment. Member assessment information for admitted members shall be completed on the day of admission to the PACT. The start and stop times for this service should be recorded in the chart.
(ii) Comprehensive assessment- is the organized process of gathering and analyzing current and past information with each member and the family and/or support system and other significant people to evaluate: 1) mental and functional status; 2) effectiveness of past treatment; 3) current treatment, rehabilitation and support needs to achieve individual goals and support recovery; and 4) the range of individual strengths (e.g., knowledge gained from dealing with adversity or personal/professional roles, talents, personal traits) that can act as resources to the member and his/her recovery planning team in pursuing goals. Providers must bill only the face-to-face service time with the member. Non-face to face time is not compensable. The start and stop times for this service should be recorded in the chart.
(B) Behavioral health service plan (moderate and low complexity by a non-physician treatment planning and review) is a process by which the information obtained in the comprehensive assessment, course of treatment, the member, and/or treatment team meetings is evaluated and used to develop a service plan that has individualized goals, objectives, activities and services that will enable a member to improve. The initial assessment serves as a guide until the comprehensive assessment is completed. It is to focus on recovery and must include a discharge plan. It is performed with the direct active participation by the member. SoonerCare compensation for this service includes only the face to face time with the member. The start and stop times for this service should be recorded in the chart.
(C) Treatment team meetings (team conferences with the member present) is a billable service. This service is conducted by the treatment team, which includes the member and all involved practitioners. For a complete description of this service, see OAC 450:55-5-6 Treatment Team Meetings. This service can be billed to SoonerCare only when the member is present and participating in the treatment team meeting. The conference starts at the beginning of the review of an individual member and ends at the conclusion of the review. Time related to record keeping and report generation is not reported. The start and stop should be recorded in the member's chart. The participating psychiatrist/physician should bill the appropriate CPT code; and the agency is allowed to bill one treatment team meeting per member as medically necessary.
(D) Individual and family psychotherapy;
(E) Individual rehabilitation;
(F) Recovery support services;
(G) Group rehabilitation;
(H) Group psychotherapy;
(I) Crisis Intervention;
(J) Medication training and support services;
(K) Blood draws and /or other lab sample collection services performed by the nurse.
(b) Behavioral Health Aide Services.
(1) Definition. Behavioral Health Aides provide behavior management and redirection and behavioral and life skills remedial training. The behavioral health aide also provides monitoring and observation of the child's emotional/behavioral status and responses, providing interventions, support and redirection when needed. Training is generally focused on behavioral, interpersonal, communication, self help, safety and daily living skills.
(2) Target population. This service is limited to children with serious emotional disturbance who are in an ODMHSAS contracted systems of care community based treatment program, or are under OKDHS or OJA custody residing within a RBMS level of care, who need intervention and support in their living environment to achieve or maintain stable successful treatment outcomes.
(3) Qualified professionals. Behavioral Health Aides must be trained/credentialed through ODMHSAS.
(4) Limitations. The Behavioral Health Aide cannot bill for more than one individual during the same time period.
(5) Documentation requirements. Providers must follow requirements listed in OAC 317:30-5-248.
(c) Family Support and Training.
(1) Definition. This service provides the training and support necessary to ensure engagement and active participation of the family in the service plan development process and with the ongoing implementation and reinforcement of skills learned throughout the treatment process. Child Training is provided to family members to increase their ability to provide a safe and supportive environment in the home and community for the child. Parent Support ensures the engagement and active participation of the family in the service plan development process and guides families toward taking a proactive role in their child's treatment. Parent Training is assisting the family with the acquisition of the skills and knowledge necessary to facilitate an awareness of their child's needs and the development and enhancement of the family's specific problem-solving skills, coping mechanisms, and strategies for the child's symptom/behavior management.
(2) Target population. Family Support and Training is designed to benefit the SoonerCare eligible child experiencing a serious emotional disturbance who is in an ODMHSAS contracted systems of care community based treatment program, are diagnosed with a pervasive developmental disorder, or are under OKDHS or OJA custody, are residing within a RBMS level of care or are at risk for out of home placement, and who without these services would require psychiatric hospitalization.
(3) Qualified professionals. Family Support Providers (FSP) must be trained/credentialed through ODMHSAS.
(4) Limitations. The FSP cannot bill for more than one individual during the same time period.
(5) Documentation requirements. Providers must comply with requirements listed in OAC 317:30-5-248.
(d) Peer Recovery Support Services (PRSS).
(1) Definition. Peer recovery support services are an EBP model of care which consists of a qualified peer recovery support specialist provider PRSS who assists individuals with their recovery from behavioral health disorders. Recovery Support is a service delivery role in the ODMHSAS public and contracted provider system throughout the behavioral health care system where the provider understands what creates recovery and how to support environments conducive of recovery. The role is not interchangeable with traditional staff members who usually work from the perspective of their training and/or their status as a licensed behavioral health provider; rather, this provider works from the perspective of their experimental expertise and specialized credential training. They lend unique insight into mental illness and what makes recovery possible because they are in recovery.
(2) Target population. Children 16 and over with SED and/or substance use disorders and adults 18 and over with SMI and/or substance use disorder(s).
(3) Qualified professionals. Peer Recovery Support Specialists PRSS must be certified through ODMHSAS pursuant to OAC 450:53.
(4) Limitations. The PRSS cannot bill for more than one individual during the same time period. This service can be an individual or group service. Groups have no restriction on size.
(5) Documentation requirements. Providers must comply with requirements listed in OAC 317:30-5-248.
(6) Service requirements.
(A) PRSS staff utilizing their knowledge, skills and abilities will:
(i) teach and mentor the value of every individual's recovery experience;
(ii) model effective coping techniques and self-help strategies;
(iii) assist members in articulating personal goals for recovery; and
(iv) assist members in determining the objectives needed to reach his/her recovery goals.
(B) PRSS staff utilizing ongoing training must:
(i) proactively engage members and possess communication skills/ability to transfer new concepts, ideas, and insight to others;
(ii) facilitate peer support groups;
(iii)assist in setting up and sustaining self-help (mutual support) groups;
(iv) support members in using a Wellness Recovery Action Plan (WRAP);
(v) assist in creating a crisis plan/Psychiatric Advanced Directive;
(vi) utilize and teach problem solving techniques with members;
(vii) teach members how to identify and combat negative self-talk and fears;
(viii) support the vocational choices of members and assist him/her in overcoming job-related anxiety;
(ix) assist in building social skills in the community that will enhance quality of life. Support the development of natural support systems;
(x) assist other staff in identifying program and service environments that are conducive to recovery; and
(xi) attend treatment team and program development meetings to ensure the presence of the member's voice and to promote the use of self-directed recovery tools.
|317:30-5-242.||Coverage for children [REVOKED]|
|317:30-5-243.||Vocational rehabilitation coverage [REVOKED]|
|317:30-5-244.||Individuals eligible for Part B of Medicare|
Outpatient Behavioral Health services provided to Medicare eligible members are filed directly with the fiscal agent.
Payment is made for Outpatient Behavioral Health services at the lower of the provider's usual and customary charge or the OHCA fee schedule for SoonerCare compensable services.
|317:30-5-246.||Covered services [REVOKED]|
|317:30-5-248.||Documentation of records|
All outpatient behavioral health services must be reflected
by documentation in the member's records.
(1) For Behavioral Health Assessments (see OAC 317:30-5-241), no progress notes are required.
(2) For Behavioral Health Services Plan (see OAC 317:30-5-241), no progress notes are required.
(3) Treatment Services must be documented by progress notes.
(A) Progress notes shall chronologically describe the services provided, the member's response to the services provided and the member's progress, or lack of, in treatment and must include the following:
(ii) Person(s) to whom services were rendered;
(iii) Start and stop time for each timed treatment session or service;
(iv) Original signature of the therapist/service provider; in circumstances where it is necessary to fax a service plan to someone for review and then have them fax back their signature, this is acceptable; however, the provider must obtain the original signature for the clinical file within 30 days and no stamped or photocopied signatures are allowed. Electronic signatures are acceptable following OAC 317:30-3-4.1 and 317:30-3-15;
(v) Credentials of therapist/service provider;
(vi)Specific service plan need(s), goals and/or objectives addressed;
(vii) Services provided to address need(s), goals and/or objectives;
(viii) Progress or barriers to progress made in treatment as it relates to the goals and/or objectives;
(ix) Member (and family, when applicable) response to the session or intervention;
(x) Any new need(s), goals and/or objectives identified during the session or service.
(4) In addition to the items listed above in this subsection:
(A) Crisis Intervention Service notes must also include a detailed description of the crisis and level of functioning assessment;
(B) a list/log/sign in sheet of participants for each Group rehabilitative or psychotherapy session and facilitating qualified provider must be maintained; and
(C) for medication training and support, vital signs must be recorded in the medical record, but are not required on the behavioral health services plan;
(5) Progress notes for PSR day programs may be in the form of daily or weekly summary notes and must include the following:
(A) Curriculum sessions attended each day and/or dates attended during the week;
(B) Start and stop times for each day attended;
(C) Specific goal(s) and/or objectives addressed during the week;
(D) Type of Skills Training provided each day and/or during the week including the specific curriculum used with the member;
(E) Member satisfaction with staff intervention(s);
(F) Progress or barriers made toward goals, objectives;
(G) New goal(s) or objective(s) identified;
(H) Signature of the lead qualified provider; and
(I) Credentials of the lead qualified provider.
(6) Concurrent documentation between the clinician and member can be billed as part
of the treatment session time, but must be documented clearly in the progress notes.
In addition to the general program exclusions [OAC 317:30-5-2(a)(2)] the following are excluded from coverage. Work and education services:
(1) Talking about the past and current and future employment goals, going to various work sites to explore the world of work, and assisting client in identifying the pros and cons of working.
(2) Development of an ongoing educational and employment rehabilitation plan to help each individual establish job specific skills and credentials necessary to achieve ongoing employment. Psycho-social skills training however would be covered.
(3) Work/school specific supportive services, such as assistance with securing of appropriate clothing, wake-up calls, addressing transportation issues, etc. These would be billed as Case Management following 317:30-5-595 through 317:30-5-599.
(4) Job specific supports such as teaching/coaching a job task.