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1 County Social Services Billing Procedure for when Social Services is the agency providing the service: STEP 2: Submit documentation to County Social Service Director. STEP 3: County Social Services Director submits approved documentation to NWMHC for reporting purposes. NWMHC compiles reporting data. expenditures incurred during the reporting quarter and a copy of the DHS-2895 to Doug Axtell at Polk County Social Services. Services provided in mental health crisis response with multi-agency response above and beyond typical job duties at the discretion of the County Director Consultation with other professionals and agencies to collaborate in management of a mental health crisis above and beyond typical job duties at the discretion of the County Director o Transportation to the initial assessment is not reimbursable o If a determination is made that additional stabilization or hospitalization is necessary at a site other than where the individual was assessed, compensation will be provided to the agency providing that transportation Training opportunities will be announced, including the number of openings to attend the training per agency type. Training costs will be paid for as well as the time to attend.

2 Sanford Medical Center Billing Procedure for when Sanford Medical Center is providing the service: STEP 2: Submit documentation to the County Social Service Director in the county the crisis occurred for screening. County Social Services makes payments to Sanford Medical Center as they are approved (not to exceed the county allocation). STEP 3: County Social Services Director submits approved documentation to NWMHC for reporting purposes. NWMHC compiles reporting data. their expenditures incurred during the reporting quarter and a copy of the DHS-2895 to Doug Axtell at Polk County Social Services. Mental health crisis assessment that does not result in immediate decision to hospitalize psychiatrically at Sanford Medical Center /Telephone Intervention Consultation with other professionals and agencies to collaborate in management of a mental health crisis o If a determination is made that additional stabilization or hospitalization is necessary at a site other than where the individual was assessed, compensation will be provided to the agency providing that transportation Crisis Stabilization Site (Northern Lights) Clients assisted and observed in a service delivery setting with access to trained staff to ensure client and staff safety Stabilization sites can only be utilized after assessment by a mental health professional Training opportunities will be announced including the number of openings at the training. Training costs will be paid for as well as the time to attend. Mental Health Professional/Practitioner On-Call Costs (this is reimbursed through quarterly billings) Weekly stipend for on-call mental health professional and practitioner (Team of 2-3) Program Administration (this is reimbursed through quarterly billings) Administrative support Mental Health Professional Consulting/On-Call Costs

3 Northwestern Mental Health Center, Inc. STEP 1: Complete documentation (via electronic medical record system - IRIS). STEP 2: NWMHC submits bill to County Social Service Director in county crisis occurred for screening. County Social Services makes payments to NWMHC as they are approved (not to exceed the county allocation). STEP 3: NWMHC compiles reporting data. Expenditures incurred during the reporting quarter and a copy of the DHS-2895 to Doug Axtell at Polk County Social Services. Mental health crisis assessment/intervention/stabilization previously non-reimbursable /Telephone Intervention Consultation with other professionals and agencies to collaborate in management of a mental health crisis Intervention provided to clients in crisis on the phone or to prevent crises Mileage reimbursement for on-call staff to respond to mental health crisis response o Transportation to the initial assessment is not reimbursable o If a determination is made that additional stabilization or hospitalization is necessary at a site other than where the individual was assessed, compensation will be provided to the agency providing that transportation Crisis Stabilization Site (Northwestern Apartments) Clients assisted and observed in a service delivery setting with access to trained staff to ensure client and staff safety Stabilization sites can only be utilized after assessment by a mental health professional Training opportunities will be announced including the number of openings at the training. Training costs will be paid for as well as the time to attend. Mental Health Professional/Practitioner On-Call Costs (this is reimbursed through quarterly billings) Weekly stipend for on-call mental health professional and practitioner (Team of 2) Program Administration (this is reimbursed through quarterly billings) 0.5 FTE Administrative support/data collection & reporting Supplies & Postage, Media/Public Information, Website Enhancement Costs for Providing and Arranging Interagency Training

4 County Law Enforcement STEP 2: Submit documentation to County Social Service Director in county crisis occurred for screening. County Social Services makes payments to respective law enforcement agency as they are approved (not to exceed the county allocation). STEP 3: County Social Services Director submits approved documentation to NWMHC for reporting purposes. NWMHC compiles reporting data. expenditures incurred during the reporting quarter and a copy of the DHS-2895 to Doug Axtell at Polk County Social Services. Post-Assessment o Transportation to the initial assessment is not reimbursable unless previous Consultation has occurred o If a determination is made that the individual requires transportation following the assessment/consultation or must be transferred for additional stabilization or hospitalization at a site other than where the individual was assessed, compensation will be provided to the agency providing that transportation Consultation with other professionals and agencies to collaborate in management of a Mental health crisis Training opportunities will be announced including the number of openings at the training. Training costs will be paid for as well as the time to attend.

5 Public Schools Can use same form for multiple contacts related to same crisis, continue to add dates on top line. Crisis assessment, intervention, and stabilization process open no more than one week. STEP 2: Submit documentation to your Mental Health Supervisor for screening and signature. STEP 3: Mental Health Supervisor will submit documentation to NWMHC, Susan Dufault for reporting purposes. NWMHC compiles reporting data. STEP 4: NWMHC will submit compiled monthly voucher to County Director for payment. County Social Services makes payments to agencies as they are approved (not to exceed the county allocation). STEP 5: Once per quarter, County Social Service Director submits a DHS-2895 to Ray Truelson for expenditures incurred during the reporting quarter and a copy of the DHS-2895 to Doug Axtell at Polk County Social Services. Mental health crisis assessment/intervention/stabilization previously non-reimbursable Consultation (in-person or by phone) with other professionals and agencies to collaborate in management of a mental health crisis Telephone Intervention Intervention provided to children in crisis on the phone to prevent crisis Mileage reimbursement for on-call staff to respond to mental health crisis response and the need for further stabilization or hospitalization is required Initial training time and monthly crisis staffing meeting with Mental Health Professional on screening, assessment, intervention, and stabilization