Retardation (MR) Section

Transcription

1 Section 32Mental Health (MH) Mental Retardation (MR) Enrollment Medicaid Managed Care Enrollment Reimbursement Benefits and Limitations Coordination and Case Management Mental Health Rehabilitative s Rehabilitative s Limitations Billing Units Claims Information Claim Filing Resources CPT only copyright 2005 American Medical Association. All rights reserved.

2 Section Enrollment To enroll in the Texas Medicaid Program, Mental Health (MH) providers must contact the Texas Department of State Health s (DSHS) at Mental Retardation (MR) providers must contact the Texas Department of Aging and Disability s (DADS) at to be approved. Local MR providers are eligible to enroll, with the approval of DADS, for MR service coordination. Local MH providers are eligible to enroll, with the approval of DSHS, for MH case management and MH rehabilitative services. Community mental health centers (CMHC) can enroll in the Texas Medicaid Program without the approval of DADS, but must be enrolled in Medicare. Refer to: Provider Enrollment on page 1-2 for more information about enrollment procedures Medicaid Managed Care Enrollment MR service coordination, MH case management, and MH rehabilitative services providers are not required to enroll with Medicaid Managed Care. Claims for MR services are submitted to TMHP for all Medicaid clients including Medicaid Managed Care clients. MH services are submitted to DSHS for all Medicaid clients including Medicaid Managed Care clients. Note: File all claims for MR service coordination with TMHP, including those for Medicaid Managed Care clients. File all claims for MH case management and rehabilitative services with DSHS, including those for Medicaid Managed Care clients. Exception: MH providers in the Dallas service area must join the NorthSTAR Behavioral Health Organizations (BHO) to provide services to NorthSTAR clients. Important: NorthSTAR is a managed care program in the Dallas service area that covers behavioral health services. MH providers who provide behavioral health services to clients in NorthSTAR must be members of the NorthSTAR BHOs Reimbursement s are reimbursed according to a maximum allowable fee established by HHSC. Reimbursement is limited to the federal matching percentage of the maximum allowable fee and is subject to adjustment annually. Refer to: Reimbursement on page 2-2 for more information about reimbursement and the federal matching percentage Benefits and Limitations Coordination and Case Management The Texas Medicaid Program provides the following service coordination and case management services: coordination for people with mental retardation or related condition (adult or child) per consumer, per month Case management for people with serious emotional disturbance (child, 3 17 years of age) Case management for people with severe and persistent mental illness (adult, 18 years of age and older) Individual Community Support s Coordination for people with mental retardation or related condition (adult or child) G9012 Once per calendar month 32 2 CPT only copyright 2005 American Medical Association. All rights reserved.

3 Mental Health (MH) Mental Retardation (MR) Routine case management (adult) T1017 TF 32 units (8 hours) per calendar day for people 18 years of age or older. Routine case management (child and adolescent) Intensive case management (child and adolescent) T1017 TF and HA 32 units (8 hours) per calendar day for people less than 18 years of age. T1017 TG and HA An MR service coordination reimbursable contact is the provision of a service coordination activity by an authorized service coordinator during a face-to-face meeting with an eligible for service coordination. To bill and be paid for one unit of service coordination per month, at least one face-to-face meeting between the service coordinator and the eligible must occur during the month billed. An MH case management reimbursable contact is the provision of a case management activity by an authorized case manager during a face-to-face meeting with an authorized to receive that specific type of case management. A billable unit of case management is 15 continuous minutes of contact. coordination and case management services are not reimbursable when provided to a client eligible for Medicaid and receiving services through the Home and Community-Based s (HCS) waiver. These services are included in the waiver. Claims submitted to TMHP for people receiving services under the HCS waiver are identified quarterly by DADS and payments are recouped. The Texas Medicaid Program must not be billed for service coordination or case management services provided to people who are residents or inpatients of: Nursing facilities (for people not mandated by the Omnibus Budget Reconciliation Act [OBRA] of 1987)* Intermediate care facilities for mental retardation (ICF_MR)* State mental retardation facilities* State mental health facilities Title XIX participating hospitals including general medical hospitals Private psychiatric hospitals Medicaid-certified residence not already specified Institutions for mental diseases such as a hospital, nursing facility, or other institution of more than 16 beds primarily engaged in providing diagnosis, treatment, or care of people with mental diseases including medical attention, nursing care, and related services Jail or public institution *A contact by the service coordinator to assist in discharge planning from some of the above may be reimbursed, if provided within 180 days before discharge. coordination services provided to people who are on predischarge furlough to the community from a nursing facility, intermediate care facility, or state mental retardation facility may be reimbursed. coordination services provided to people who are on trial placement from a state mental retardation facility to the community may be reimbursed if the person remains eligible for Medicaid upon release from the facility and receives regular Medicaid coverage. The Texas Medicaid Program must not be billed for MH case management services provided before the establishment of a diagnosis of mental illness and authorization of services. Refer to: Managed Care on page 7-1 for more information or contact the client s BHO. Do not bill TMHP for MH case management services rendered to NorthSTAR clients Mental Health Rehabilitative s The following rehabilitative services may be provided to s who satisfy the criteria of the mental health priority population and who are determined to need rehabilitative services. These services may be provided to a person with a single severe mental disorder (excluding mental retardation, pervasive CPT only copyright 2005 American Medical Association. All rights reserved. 32 3

4 Section 32 developmental disorder, or substance use disorder) or a combination of severe mental disorders as defined in the latest edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): Day program for acute needs G units (4.5 to 6 hours) per G0177 HK Day program for acute needs, Assertive Community Treatment (ACT), or ACT alternative client adult, adult, ACT or ACT alternative client, adult, adult, ACT or ACT alternative client, child and adolescent, Individual child and adolescent with other child and adolescent, child and adolescent with other HK HK and calendar day, in any combination, for people 18 years of age or older 8 units (2 hours) per calendar day in any combination, for people 18 years of age or older. HA 8 units (2 hours) per calendar day in any combination, for HA and HR or UK HA and HA and and HR or UK people less than 18 years of age. Crisis intervention services, adult H units (24 hours) per calendar day in any Crisis intervention services, adult, H2011 HK combination ACT or ACT alternative client Crisis intervention services, child and adolescent H2011 HA adult, adult, child and adolescent, child and adolescent, with other, H2014 H units (4 hours) per calendar day, in any combination, for people 18 years of age or older H2014 HA 16 units (4 hours) per calendar day, in any combination, for H2014 HA and HR or UK people less than 18 years of age 32 4 CPT only copyright 2005 American Medical Association. All rights reserved.

5 Mental Health (MH) Mental Retardation (MR) ACT or ACT alternative client, by RN, Psychosocial rehabilitative services ACT or ACT alternative client, by registered nurse (RN), ACT or ACT alternative client, by RN, ACT or ACT alternative client, by RN, Individual, crisis ACT or ACT alternative client, Individual, crisis HK 16 units (4 hours) per calendar day, in any combination, for people 18 years of age or older TD HK and TD and HK and TD and HK and TD ET HK 96 units (24 hours) per calendar day, in any combination and ET Rehabilitative s Limitations The Texas Medicaid Program must not be billed for rehabilitative services provided before the establishment of a diagnosis of mental illness and authorization of services; rehabilitative services provided to s who reside in an institution for mental diseases; rehabilitative services provided to general acute care hospital inpatients; vocational services; educational services; nursing facility residents who are not mandated to need services by OBRA of 1987; and services provided to s in jail or a public institution. Refer to: Title 25 Texas Administrative Code (TAC), Part I, Chapter 419, Subchapter L and the Medicaid MH Rehabilitative Billing Guidelines for more information Billing Units All claims for reimbursement for rehabilitative services are based on the actual amount of time the eligible or primary caregiver/legal guardian of an eligible is engaged in face-to-face contact with a service provider. The billable units are:, (15 continuous minutes); day programs (45-60 continuous minutes) Claims Information Submit MR service coordination services to TMHP in an approved electronic claims format or on a CMS paper claim form. Providers must purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply them. Submit MH case management and rehabilitative services to the DSHS Resiliency and Disease Management (RDM) translator in the approved formats. Refer to: RDM Medicaid Claims Billing Process for Mental Health Rehabilitative and Case Management s. CPT only copyright 2005 American Medical Association. All rights reserved. 32 5

6 Section Claim Filing Resources Refer to the following sections and/or forms when filing claims: Page Resource Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange (EDI) 3-1 CMS-1500 Claim Filing Instructions 5-24 TMHP Electronic Claims Submission 5-10 Communication Guide A-1 Mental Health Case Management Claim D-22 Example Acronym Dictionary F CPT only copyright 2005 American Medical Association. All rights reserved.