Department of Medical Assistance Services

1. Department of Medical Assistance Services COMMUNITY MENTAL HEALTH REHABILATATIVE SERVICES September 2008

2. ************ This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals Training material contains only highlights of manuals and is not meant to substitute for or take the place of the Community Mental Health Rehabilitative Services Manual. For a complete copy of manual: www.dmas.virginia.gov

3. Accessing CMHRS ManualFrom DMAS Website www.dmas.virginia.gov After accessing the DMAS website ---follow and click at the red arrow markers (displayed only the slide) to obtain the CMHRS manual

8. Objectives of Today’s Training • Review general Medicaid provider requirements & staff credentials • Discuss Crisis Intervention • Discuss Crisis Stabilization • Discuss Intensive Community Treatment • Discuss Mental Health Support Services • Discuss Mental Health Targeted Case Management • Discuss Utilization Review • Closing questions

9. General Medicaid Participation Requirements: The Provider agency holds a current, signed participation agreement with DMAS and meets the following: • Holds in good standing required licensure • Has administrative and financial management capacity to meet state and federal requirements. • Has the ability to serve individuals needing comprehensive services • Provides like quality services to all clients

10. Participation Requirements (cont’d) For recipients providers must: Assure freedom to accept or reject medical care and treatment Assure freedom of choice of provider Alert recipient to notification of the right to appeal

11. Participation Requirements(cont’d):Providers must: Document and maintain individual case records in accordance with state and federal guidelines Holds information regarding recipients confidential. Maintain records for a period of not less than 5 years

12. Participation Requirements (cont’d): • Be fully compliant with state and federal HIPAA confidentiality, use and disclosure requirements

13. Participation Requirements (cont’d):Providers must: Not exceed the provider’s usual and customary charges to the general public. Accept as payment in full the amount reimbursed by Medicaid for recipient. Should not attempt to collect from the recipient or family member any amount that exceeds the Medicaid allowance.

14. Provider Enrollment First Health/Provider Enrollment Unit (FH/PEU) For enrollment, agreements, change of address, and enrollment questions: First Health VMAP Provider Enrollment Unit P.O. Box 26803 Richmond, Va. 23261-6803 Helpline -- 804-270-5105 – Richmond (in state)Toll free -- 888-829-5373 Fax -- 804-270-7027

15. Specific Staff Qualifications • DMAS defines a Licensed Mental Health Professional to be a: • Physician • Licensed Clinical Psychologist • Licensed Professional Counselor (LPC) • Licensed Clinical Social Worker (LCSW) • Licensed Marriage and Family Therapist • Psychiatric Clinical Nurse Specialist • Nurse Practitioners

16. Staff Qualificationscont. • Qualified Mental Health Professional – Clinician in the human service field, trained and experienced in providing psychiatric/mental health services to individuals with a psychiatric diagnosis.

17. Human Services Fields • Social Work • Gerontology • Psychology • Psychiatric Rehabilitation • Special Education • Sociology • Counseling • Vocational Rehabilitation • Human Services Counseling • Nursing

18. Definition of“Clinical Experience” • Providing direct services to individuals with: • Mental illness • Mental retardation • Persons receiving gerontology services • Persons receiving special education services • Includes supervised internships, practicums and field experience.

19. Staff Qualifications (cont’d) Qualified Mental Health Professional (cont’d) • Psychologist: master’s degree in psychology with at least one year of clinical experience; • Social worker: master’s or bachelor’s degree with a least one year of clinical experience; • Registered nurse: RN licensed in Virginia with at least one year of clinical experience;

20. Staff Qualifications (cont’d)Qualified Mental Health Professional (cont’d) Mental Health Worker: • bachelor degree in human services field with one year clinical experience; OR • bachelor’s degree in unrelated field with associates in human services field & three years clinical experience; OR • bachelor’s degree in unrelated field with at least 15 semester credits in human service field & three years clinical experience; OR • four years clinical experience working directly with individuals with mental illness

21. Staff Qualifications (cont’d) Qualified Para-Professional • AA Degree in related field with one year clinical experience; OR • AA Degree in unrelated field with three years clinical experience; OR • College credits in human service field equivalent to AA degree or higher with one year clinical experience; OR • Licensed Practical Nurse with one year clinical experience

22. “PARAPROFESSIONAL SUPERVISION” • QMHP demonstrates supervision of “Qualified Paraprofessional” by reviewing notes, progress towards achieving ISP goals & objectives and making recommendations for change. • Supervision must occur & be documented in the clinical record monthly. • Individual & group supervision conducted by the QMHP are acceptable.

23. Non-Qualified Paraprofessionals Paraprofessionals who do NOT meet the experience requirement described may provide services….. • if they are working directly with a Qualified Paraprofessional on site and • they are supervised by a QMHP. Supervision must include on site observations of services, face -to-face consultation, review of notes, etc. and be documented in the clinical record monthly.

24. All OF THE COMMUNITY MENTAL HEALTH SERVICES….. have four specific components: • Service Definition • Eligibility requirements • Activities which are required • Limitations of the Service

25. Order of UR Forms in Handout Packet • Crisis Intervention, • Crisis Stabilization, • Intensive Community Treatment, • Mental Health Support, • MH Case Management, & • Psychosocial Rehabilitation- (not a part of CMHRS Fall Training, but we will be available for PSR questions during lunch) Link to WebEx recorded training is as follows: https://dmas.webex.com/dmas/k2/e.php?AT=RINF&recordingID=10323587

26. Crisis Intervention Services (H0036)

27. Crisis Intervention: SERVICE DEFINITION FOR NON-HOSPITALIZED INDIVIDUALS • Direct mental health care, available 24 hours a day, 7 days per week, to provide assistance to individuals experiencing an acute mental health dysfunction requiring immediate clinical attention.

28. Service Definition(cont’d) The objectives of crisis intervention services are: • To prevent exacerbation of a condition; • To prevent injury to the recipient or others; and • To provide treatment in the least restrictive setting

29. Crisis Intervention Services Required Licensing Information • Crisis Intervention providers must be licensed as a provider of Outpatient Services by DMHMRSAS; • Appropriate staff (LMHP, QMHP or certified prescreener) conducts the evaluation or assessment, develops the ISP and delivers the service

30. Eligibility Criteria: CRISIS INTERVENTION SERVICES : • Are provided following a marked reduction in the recipient’s psychiatric, adaptive or behavioral functioning or an extreme increase in personal distress • Can be provided for an individual with co-occurring mental health and substance abuse services as long as treatment for the substance abuse is intended to positively impact the mental health condition

31. Required Activities: The Crisis Intervention program includes: • Psychiatric assessment & medication evaluation • Treatment planning • Symptom and behavior management • Short term individual counseling • Referrals to appropriate community resources

32. Required Activities(cont’d): A Certified CSB Prescreener, LMHP or QMHP must: • Complete and document a face-to-face assessment of the crisis situation, including the anticipated duration, that warrants the need of the service; • Review/Approval of this documentation must be made by an LMHP/certified prescreener within 72 hours (if completed by a QMHP) • Provide immediate needed services to the client in the least restrictive setting

33. Required Activities,(cont’d): SERVICES MAY INCLUDE: • Home or office visits • Telephone contacts/community referrals (or other client-related activities for the prevention of institutionalization) • Interventions that include the individual’s family or significant other • Preadmission screenings* • *Only CSBs can do pre-admission screenings

34. Required Activities (cont’d): • As appropriate, the client should be referred for a physical examination and this referral should be documented in the record. • The quantity and dosage of any prescribed drugs should be documented in the record. • As appropriate, Freedom of Choice of medical/psychiatric providers and Appeal Rights should be given to recipient and documented in the record.

35. ISP’s and Short Term Counseling: • An ISP is not required for crisis intervention services • An ISP is required for scheduled short-term counseling • The short-term counseling contacts must occur within 30 days of the first face-to-face crisis contact

36. ISP’s and Short Term Counseling (cont’d): • An ISP prepared by a Certified Pre-Screener or QMHP by the FOURTH face- to- face contact must be developed or revised to reflect treatment goals and interventions for scheduled short term counseling. • Inclusion of the service on the existing ISP is not required for the service to be provided to an active recipient on an emergency basis.

37. Service Units & Maximum Service Limitations: • Crisis Intervention (H0036) and Crisis Stabilization (H2019) may not be billed if the client is receiving Intensive In- Home Services • If other clinic services are billed while the individual is receiving Crisis Intervention services, documentation must clearly support the separation of services with distinct treatment goals

38. Manual States No CI billing During IIH: • Crisis intervention is a part of intensive in-home services and should not be billed separately when a Medicaid recipient is also receiving intensive in-home services.  • CSB Emergency Services staff respond to internal and external requests to provide CI services for clients, and are sometimes unaware of the client’s involvement in IIH.  1. Crisis staff should ask the child or adolescent and any accompanying adult (if applicable) if they are receiving any other services from any other provider, specifically intensive in-home services.  The question and answer should be clearly documented in the client record. 

39. No CI During IIH(cont’d): • If the answer is no, provide the crisis service and proceed to item #2 below. • If the answer is yes, provide the needed crisis service and then contact the private provider if possible.  This crisis intervention service should not be billed to Medicaid. 2. During the next business day, Medicaid may be contacted to determine if any provider is rendering intensive in-home services to the client.  The result of this investigation should be documented.

40. No CI During IIH(cont’d): • If the answer is yes, CI should not be billed to Medicaid • If the answer is no, the crisis services can be billed to Medicaid **Please note, this process is not applicable for those situations where a CSB is responding to the request to perform a prescreening for potential ECO or TDO.  For those situations, a CSB will be allowed to bill crisis intervention services regardless of whether the client is receiving intensive in-home services from a private provider.  

41. No CI or CS During IIH(cont’d): • CI providers may review the clients’ services on the Medicaid web site/Provider Help Line prior to billing. • Other service providers with releases may be contacted to investigate clients’ involvement. • CI providers should clearly document all attempts to gather this information. • Preadmission screenings for these IIH recipients are billable under the CI service code. • During a UR, this documentation will likely avoid the need for the repayment of crisis services.

42. Service Units & Maximum Service Limitations(cont’d): • A face-to-face contact with the consumer must occur during the crisis episode. • Other contacts, such as telephone calls and collateral contacts during the crisis episode, are reimbursable as long as the requirement for a face-to-face contact is met and the contacts are directed toward crisis resolution.

43. Service Units & Maximum Service Limitations(cont’d): • Reimbursement will be provided for short-term crisis counseling contacts scheduled within a 30-day period from the time of the first face-to-face crisis contact.

44. Service Units & Maximum Service Limitations(cont’d): NOTE: • Medicaid cannot be billed when a recipient is under Emergency Custody Orders (ECOs) or Temporary Detention Orders (TDOs). • Services may be billed up to the time an order is received and after evaluation for ECO/TDO is complete. • Documentation must clearly delineate the separation of time.

45. Service Units & Maximum Service Limitations (cont’d): • A unit of service is 15 minutes of Crisis Intervention • A Maximum of 720 units of Crisis Intervention can be provided annually. • Staff travel time is not billable

46. Crisis Intervention Do’s & Don’ts • Do document the time spent in service delivery---including collateral contacts • Don’t bill for crisis services after TDO or ECO has been issued

47. Questions

48. Crisis Stabilization Services (H2019)

49. Outpatient Service Provider Specific Licensure Requirements for this mental health service: Crisis Stabilization providers must be licensed by DMHMRSAS as a provider of Outpatient Services

50. Crisis Stabilization (H2019) SERVICE DEFINITION Crisis stabilization services: • direct mental health care • to non-hospitalized individuals of all ages who are experiencing an acute crisis of a psychiatric nature that may jeopardize their current community living situation.