To Access Community Center Rehabilitative Behavioral Health Services (RBHS)

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2 To Access Community Center Rehabilitative Behavioral Health Services (RBHS) I. Who Can Make Referrals Representatives from the following South Carolina State agencies may make referrals/authorize Rehabilitative Behavioral Health Services (RBHS) for beneficiaries who meet medical necessity requirements: Department of Social Services Department of Mental Health Continuum of Care Department of Disabilities & Special Needs Department of Juvenile Justice Department of Education and Local Education Agencies II. How to Make a Referral There are two ways to make a referral: 1) Fax a copy of a completed DHHS Form 254 along with a completed Medical Necessity Statement (MNS); or 2) Fax a copy of a completed DHHS Form 254 along with the completed Individual Plan of Care (IPOC). DHHS Form 254 and the Medical Necessity Statement (MNS) are available at all authorized state agencies. If you need any of these forms, or are not familiar with these forms, contact your supervisor or director for more information on how to obtain the forms. See Attached Sample Forms DHHS Form 254 & MNS (with recommended values for the Extended Day Summer Program participation).

3 III. Sample Forms DHHS Form 254 & Medical Necessity Statement The following sample DHHS Form 254 and Medical Necessity Statement are filled out according to the recommendations for one year (52 weeks) of participation in Access Community Center Extended Day Programs (After School and Summer). Keep in mind that the values in the sample forms are recommendations. The referring agency makes the final decision on the services and the amounts of units authorized. Contact Access Community Center with any questions regarding referrals: (803)

4 REFERRAL FORM / AUTHORIZATION FOR REHABILITATIVE SERVICES FORM 254 NATIONAL PROVIDER IDENTIFIER # BENEFICIARY S MEDICAID # REFERRED TO: AUTHORIZATION DATE: EXPIRATION DATE: Name County Address Last Date of Service Date of Birth Sex Agency Reference No. City State Zip Prior Authorization Number (1 st two letters reflect the agency s origin. Remaining 5 characters are left up to referring agency or SCDHHS QIO.) Parent/Guardian The provider named above is hereby authorized to render the following service(s) on or within the designated time period for the Medicaid-eligible beneficiary which is not to exceed12 months. The number of units and staff to provide services should be based on the medical needs of the beneficiary and from the referral source. Please refer to the Rehabilitative Behavioral Health Service Provider Manual for Modifiers and Procedure codes. Only the number of units authorized may be billed. Procedure Code Modifier Assessment Services 1 Behavioral Health Screening H minutes 2 Diagnostic Assessment Initial Per Encounter 3 Diagnostic Assessment Follow up Per Encounter 4 Psychological Testing / Evaluation AH 60 minutes 5 Comprehensive Evaluation Initial H2000 Per Encounter 6 Comprehensive Evaluation Follow up H0031 Per Encounter 7 Alcohol & Drug Assessment Follow up H0001 Per Encounter Treatment Plan Development and Modification Services 8 Service Plan Development (Mental Health) H minutes 9 Service Plan Development (Team w/ Client minutes 10 Service Plan Development (Team w/o Client) minutes Therapy Services 11 Individual minutes 12 Group minutes 13 Family w/o client minutes 14 Family w/ client minutes Community Support Services 15 Crisis Management H minutes 16 Medication Management H minutes 17 Service * H minutes 18 Behavior Modification (BMod) * H minutes 19 Family Support * S minutes 20 Peer Support* H minutes *Service(s) not authorized by the SCDHHS QIO. Unit Total Units Authorized Frequency Authorizing Agency: (One must be marked ) Department of Social Services Department of Mental Health Continuum of Care For Emotionally Disturbed Children Department of Disabilities and Special Needs Department of Juvenile Justice School District / Department of Education United Way SCDHHS Quality Improvement Organization Authorized Agency Representative Title Phone Signature Date State Agency Use Only: DHHS Form 254 (Revised 08/2010) Original Provider Copy Referring State Agency Copy SCDHHS State Office

5 MEDICAL NECESSITY STATEMENT FOR REHABILITATIVE SERVICES Beneficiary s Name: Date of Birth: Social Security Number: Medicaid Number: Diagnosis code(s): [Diagnosis codes must be based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD).] I recommend that the above-named Medicaid beneficiary receive Rehabilitative Services(s) for the maximum reduction of emotional, behavioral, and functional developmental delays and restoration of the beneficiary to his or her best possible functioning level. This beneficiary meets the Medical Necessity criteria for Rehabilitative Services as evidenced by a Psychiatric diagnosis from the current edition of the DSM or the ICD. Indicate the specific Rehabilitative Service(s) being recommended on each line below. Identify the Beneficiary s problem areas for Rehabilitative Services listed above. The recommendation must be based on recent clinical information, staffing recommendations, review(s) of treatment history and/ or evaluation(s) made within federal and state standards (Signature of Physician or other Licensed Practitioner of the Healing Arts) (Please print name signed above) (Professional Title) (Phone Number) Signature Date: (Services must be initiated within 45 calendar days.) Must be handwritten Note: The Referral/Authorization for Rehabilitative Services form (DHHS Form 254) and the MNS must be sent to the provider prior to the provision of services, or at the time the services are rendered. Revised: 05/2010

6 Program Specific Recommended Values for DHHS Form 254 Extended Day Programs - Both After School & Summer (52 weeks) (values are for half day during summer session and traditional after school hours during inschool session) HO units / day Extended Day Program Summer (13 weeks) (Half Day) HO units / day (Full Day) HO units / day Extended Day Program After School (39 weeks) HO units / day Adult Day Treatment (52 weeks) HO units / day

7 Recommended Values for DHHS Form 254 (General) Modifier Total units for 3 months (13 weeks) of service Total units for 6 months (26 weeks) of service Total units for 1 year (52 weeks) of service Frequency Individual Therapy HO units / week Family Therapy w/o Client Family Therapy w/ Client Rehab Psychosocial Behavior Modification H2014 HO units / week HO units / week HO units / day HO units / week Family Support S9482 HO units / week Service Plan Development (Mental Health) H0032 HO units / contract Summary of Chart: All services at Access Community Center are provided by Master s Level Professionals (Modifier HO). The length of treatment typically ranges from 3 to 12 months. Typical frequencies for services are as follows: Individual Therapy 1 hour per week (2 units/week) Family Therapy w/client 2 hour per week (4 units/week) Services 4 hours per day (16 units/day) Behavior Modification 2 hours per week (8 units/week) Family Support 1 hour per week (4 units/week) Services Plan Development 3 hours per authorization (12 units)