All ACBHCS County & Contracted Mental Health (MH) Providers. Updated ACBHCS Specialty MH Services (SMHS) FAQ s

Transcription

1 ALCOHOL, DRUG & MENTAL HEALTH SERVICES DON KINGDON, PhD, INTERIM DIRECTOR Quality Assurance Office 2000 Embarcader Cve, Suite 400 Oakland, Califrnia (510) / TTY (510) DATE: August 8, 2017 TO: FROM: RE: All ACBHCS Cunty & Cntracted Mental Health (MH) Prviders ACBHCS Quality Management Department Updated ACBHCS Specialty MH Services (SMHS) FAQ s QA has revised, and is psting, the ACBHCS Specialty MH Services (SMHS) FAQ s n the Prvider Website. (Revised and New FAQ s are in red.) See: New r revised tpics include: An Index MH Assessment: Cultural & Linguistic Cnsideratins (including required Sexual Orientatin & Gender Identity data cllectin fields); Diagnses & Safety. ACBHCS System f Care Auditing CANS/ANSA Dcumentatin Standards Claiming SMHS revisins Infrming Materials revisins Client Plans If yu have any questins abut these FAQ s, yur Quality Assurance Crdinatr may cntact the QA TA cntacts as belw. T receive ntice f all quality assurance annuncements and updates, subscribe t receive autmatic s at: Scrll dwn t stay in tuch with QA, click n e-subscribe, and enter yur cntact infrmatin. A Department f Alameda Cunty Health Care Service Agency

2 Index: ALAMEDA BEHAVIORAL HEALTH CARE SERVICES (ACBHCS) New/Revised (frm v ) FAQ s in Red. Fr Mre Cmprehensive Guidelines see the MH Prvider Manuals: I. Assessment: Cultural & Linguistic Cnsideratins; Diagnses; Safety II. ACBHCS System f Care Auditing III. Beneficiary Rights IV. CANS/ANSA Dcumentatin Standards V. Claiming SMHS VI. Grievances & Appeals VII. Infrming Materials VIII. Medicare-Medi-Cal Cncurrent Claiming IX. Scpe f Practice X. Therapeutic Behaviral Services XI. Day Rehabilitatin & Day Treatment Intensive XII. Client Plans I. Assessment Cultural & Linguistic Cnsideratins Q1. What Sexual Orientatin and Gender Identity/Expressin (SO/GIE) data must be cllected at Initial and Annual Assessment. A1. The fields are as fllws: Fr Prnun, Gender Identity & Sexual Orientatin select all that apply. Page1

3 Q2. Are there ther SO/GIE cnsideratins when develping the Assessment template r when inquiring with the client and/r family? A2a. Yes, rather than asking abut Mther r Father, ask abut Parents, Caretakers (inclusive f extended family) r Guardians. A2b. Als, Rather than asking is smene is married r has a husband r wife, ask if they have a Significant Other r Dmestic Partner. Diagnses Q1. What are the charting diagnses requirements? A1. Diagnses dcumented in the client s clinical recrd, such as a paper chart r an EHR, must represent the client s full DSM-5 diagnstic picture. It must include the same diagnses entered int InSyst, plus any additinal diagnses the client may have. Diagnses in the clinical recrd must be supprted by dcumentatin including: specific signs, symptms, and timeframes f the diagnses that client exhibits unless it is a diagnsis gathered by histry and is nt a fcus f treatment. All Diagnses must include the ICD-10 cde and the apprpriate DSM descriptr (diagnsis name) with specifiers and severity (when apprpriate). See SMHS FAQ, Sectin V. Claiming SMHS, and Q24 fr InSyst diagnses requirements. Safety Q1. If a client is fund t have suicidal/hmicidal/ther significant risk ideatin is a Safety Plan required? A1. Yes, if at any pint ideatin is identified (having ccurred anytime in the past 90 days)--bth a cmprehensive Risk Assessment AND a frmal written Safety Plan must be develped in crdinatin with the client. Als, see Q2 belw. Q2. What if a client has a histry f suicidal/hmicidal/ther significant risk ideatin but is currently stable and has these symptms cntrlled. A2. ACBHCS requires that if a client has had any a suicidal/hmicidal/ther significant risk ideatin in the past 90 days that bth a cmprehensive Risk Assessment AND a frmal written Safety Plan must be develped in crdinatin with the client. If it has been mre than 90 days since the client last experienced symptms f suicidal/hmicidal/ther significant risk ideatin the clinical situatin must be cnsidered carefully t determine if a cmprehensive Risk Assessment AND a frmal Safety Plan shuld be cmpleted. Beynd 90 days f ideatin, if it is determined that a Cmprehensive Risk Assessment and frmal written Safety Plan are nt indicated, dcument the clinical reasning fr this decisin. Page2

4 Q3. What elements must be dcumented in a cmprehensive Risk Assessment and frmal Safety Plan? A3. The Cmprehensive Risk Assessment must be dcumented in the Clinical Recrd. The Safety Plan must als be dcumented in writing and prvided t the client as a resurce fr reference as needed. It is crucial that the develpment f the Plan is a clinical prcess and that each step is embraced and endrsed by the client. Critical elements f each include: Cmprehensive Risk Assessment (must be dcumented in Clinical Recrd): Reasn fr Cmprehensive Assessment Current Episde: Current Intent (Subjective Reprts & Objective Signs); Plans; Access t Means; and Ideatin (Frequency, Intensity & Duratin) Histry f Risks and Attempts (Self-Harm, Risk t Others, & Hspitalizatins related t Risk) Risk Factrs (Internal, & Envirnmental) Prtective Factrs (Internal, & Envirnmental) Fcused Symptm Severity (Depressin, Anxiety, Anger, Agitatin, Insmnia, Hpelessness, Perceived Burdensmeness, Impulsivity/Self Cntrl, Chrnic Risk, Therapeutic Alliance, and Current Level) Status f Crisis Safety Plan Cmprehensive Risk Assessment Resurce: Hmicide_Risk_Assesment.pdf Frmal Crisis Safety Plan (written frm client s perspective as their plan). What are my Warning Signs (Thughts, Images, Thinking Prcesses, Md & Behavir)? What Are My Triggers? What Internal Cping Strategies may I Use (Identificatin f, Likelihd f Use, Barriers and Prblems Slving)? What Scial Cntacts May I Use (Fr Distractin &/r fr Supprt multiple peple in multiple settings)? When Will I cntact my Family Members and/r Friends t Assist in the Reslutin f the Crisis? Which, and When Will I Cntact, Prfessinals and Agencies fr Assistance (Pririty & Expectatins)? Hw May I Reduce the Ptential fr Use f Lethal Means? Page3

5 The Implementatin f Safety Plan (Likelihd f Use and Prblem Slve if Obstacles; Regular Review) Resurce: II. ACBHCS System f Care Auditing: Q1. When a chart is chsen by Alameda Cunty t be audited, will the cunty recup mney fr prgress ntes/claims that fail t meet Medi-cal ACBHCS dcumentatin standards? A1. All prviders and regulatrs have a legal and ethical duty t reduce fraud, waste, and abuse. All claims during the audit perid (ften 3 mnths f services) are examined t assure that the services prvided supprt the claims assciated with them. If dcumentatin des nt meet minimum dcumentatin requirements t supprt the service/claim, Alameda Cunty will recup thse funds and return them t the funding surce. Q2. What is a quality cmment? Will a claim be recuped if there is a quality cmment abut it? A2. Often charts will include enugh infrmatin t supprt the claim but will have quality issues. In these instances, feedback describing the quality issues will be prvided and require a Quality Imprvement Plan n the part f the agency t assure imprved dcumentatin in the future. These claims are nt recuped, but such future claims with pr quality may be recuped--especially if a prgram fails t imprve the quality f their dcumentatin in the future. Q3. Why are claims utside f the audit perid recuped? A3. In the curse f reviewing a chart, if it is determined that claims utside f the audit perid are als nt supprted by dcumentatin in the chart, there is a legal and ethical duty t recup thse funds and return them t the funding surce. Q4. What type f dcumentatin prblems wuld cause claims utside f the audit perid t be identified as needing recupment? A4. The mst cmmn reasns fr claims utside the audit perid being recuped include: 1: Assessments reviewed were: nt cmpleted, nt signed, late, etc. (see DHCS Reasns fr Disallwances with ACBHCS Cmments). 2: Treatment plans reviewed were: nt cmpleted, nt signed, late, r service mdality claimed was nt listed, etc. Page4

6 3: The Severity Screening Tl did nt supprt that the client has mderate t severe impairment t functining and therefre was nt eligible fr specialty mental health Medi-Cal services. ACBHCS makes available n the cunty s web pages the full set f criteria and regulatins that are used during the audit prcess. Please refer t thse exhibits fr a full list f items that when fund deficient will cause claims t be disallwed. Audit Tls fr Mental Health Services Audit Tls 1. Regulatry Cmpliance Tl 2. Plan f Crrectin and Quality Imprvement Plan Template 3. DHCS & ACBHCS Reasns fr Recupment - updated 7/1/16 4. Standard Abbreviatins Diagnses Lists and Crsswalks: 1. ACBHCS Mental Inpatient Medi-Cal Included Dx List Alpha by DSM-5 Name 2. ACBHCS DSM-IV t DSM-5 Mental Health Included Dx Crsswalk by DSM-5 Chapters 3. ACBHS Mental Inpatient Medi-Cal Included Dx List Numeric by ICD-10 Cdes 4. ACBHCS Mental Health Outpatient Medi-Cal Included Dx List Alpha by DSM-5 Name 5. ACBHCS General Medical Cdes 6. ACBHCS Psychscial Dx List Alpha by DSM-5 Name 7. ACBHCS Psychscial Dx List Numeric By ICD-10 Cde MH Authrizatin and Audit Tls: 1. ACBHCS M/C Claiming Lck-Out Grid 2. DHCS & ACBHCS Reasns fr Recupment 3. ACBHCS MH CQRT Frm Adult Child 4. Regulatry Cmpliance Tl 5. Plan f Crrectin and Quality Imprvement Plan Template 6. ACBHCS SMHS FAQ s Mental Health Prvider Manuals: 1. Quality Assurance Manual 2. ACBHCS MH Clinical Dcumentatin Standards Manual fr Master Cntract Prviders 3. ACBHCS MH Clinical Dcumentatin Standards fr SMH Fee Fr- Service Prviders (MHP Netwrk Prviders) 4. ACBHCS MH CQRT Manual Page5

7 Medi-Cal Cmpliant Clinical Frms and Templates Sample Medi-Cal Cmpliant Initial r Annual MH Assessment Lng Frm Sample Medi-Cal Cmpliant Initial MH Assessment Shrt Frm Sample Medi-Cal Cmpliant Psychiatric Mental Health Assessment: PDF Wrd Sample Medi-Cal Cmpliant Psychiatric Mental Health Client Plan: PDF Wrd Sample Medi-Cal Cmpliant Outpatient MH Prgress Nte: PDF Wrd Sample Medi-Cal Cmpliant MH Treatment Plan: PDF Wrd III. Beneficiary Rights Q1. The MHP Cntract (with CA DHCS), Exhibit A, Attachment 3, Item N. 4 states that a beneficiary may "request and receive a cpy f his r her medical recrds, and request that they be amended r crrected." Can prviders verride such a request if it is nt in the best interest f the patient, clinically? A1. This particular beneficiary right incrprates parts f the HIPAA privacy rule. The exact language f Title 42, CFR, Sectin (b)(2)(vi) states: "If the privacy rule, as set frth in 45 CFR parts 160 and 164 subparts A and E, applies, [the beneficiary has the right t] request and receive a cpy f his r her medical recrds, and request that they be amended r crrected, as specified in CFR Secs and " Since MHPs are subject t the HIPAA privacy rules, they must grant beneficiaries this right, unless ne f the exceptins applies. This is nt a brand new requirement; MHPs were already subject t this when the HIPAA privacy rule became effective in April Title 45, CFR Sectin describes an individual's rights and exceptins t accessing their recrds. This sectin ( (a)(3)(i)) addresses situatins in which accessing the infrmatin wuld nt be in the best interest f the beneficiary. (i) A licensed health care prfessinal has determined, in the exercise f prfessinal judgment, that the access requested is reasnably likely t endanger the life r physical safety f the individual r anther persn; (ii) The prtected health infrmatin makes reference t anther persn (unless such ther persn is a health care prvider) and a licensed health care prfessinal has determined, in the exercise f prfessinal judgment, Page6

8 that the access requested is reasnably likely t cause substantial harm t such ther persn; r (iii) The request fr access is made by the individual s persnal representative and a licensed health care prfessinal has determined, in the exercise f prfessinal judgment, that the prvisin f access t such persnal representative is reasnably likely t cause substantial harm t the individual r anther persn. The full text f Title 45, CFR, Sectin can be accessed here: Title 45, CFR, Sectin describes the amendment prcess fr changing medical recrds, and the exceptins. The full text f Title 45, CFR, Sectin can be accessed here: IV. CANS/ANSA Dcumentatin Standards Q1: When d I need t cmplete the CANS r ANSA? A1: The CANS r ANSA must be cmpleted at the fllwing timeframes: At Opening. The Initial CANS/ANSA must be cmpleted within 60 calendar days f the Episde Opening Date (EOD), but after cmpletin f the MH Assessment and prir t the cmpletin f the Client Plan. CANS/ANSA data/infrmatin shall be used t infrm the Initial Client Plan. At the 6-mnth mark. A Re-Assessment CANS/ANSA must be cmpleted within the calendar mnth prir t the 6th mnth f the EOD. At Annual Re-Authrizatin. A Re-Assessment CANS/ANSA must be cmpleted during the annual re-authrizatin timeframe which is within the calendar mnth prir t the episde pening mnth. CANS/ANSA data/infrmatin shall be used t infrm the annual Client Plan. Upn a clinically significant change. Once the Initial CANS/ANSA is cmpleted, staff must re-administer the CANS/ANSA whenever a clinically significant change ccurs r need arises. This CANS/ANSA re-assessment culd signal the need t update the Client Plan. Client Plan Update (New Plan is created). Cnversely, since the CANS/ANSA is used t infrm the Client Plan, the CANS/ANSA must be updated with every Client Plan update. That is, when planning t cmplete a new Client Plan, first Page7

9 administer the CANS/ANSA and then utilize that additinal infrmatin t infrm the new Client Plan. At Discharge. A CANS/ANSA must be cmpleted prir t clsing the case. Q2: If we cmplete the CANS r ANSA in the Objective Arts database (rather than n paper frm) d I need t print it ut? A2: Yes. Since the CANS/ANSA dcument is part f the fficial medical recrd, the print ut shuld be included in the cnsumer s chart (medical recrd). Staff must sign (electrnic signature is kay) with credentials, required c-signatures, and date. Cmpleting it by paper fr the medical recrd, r within an Electrnic Health Recrd is als acceptable. Hwever, nce the CANS/ANSA is cmpleted n paper smene will need t d data entry f the results int the Objective Arts database which is nt a claimable service. Q3: I m credentialed as a MHRS r Adjunct Staff; can I cmplete the CANS r ANSA? A3: N. Due t the clinical nature f the CANS/ANSA, staff wh cmpletes a CANS/ANSA must meet the credentialing standards as in the categry f Evaluatin (CANS/ANSA) n the BHCS Guidelines fr Scpe f Practice Credentialing grid. That is, Licensed, r Unlicensed (Waivered r Registered) LPHA s; OR Graduate MH Student/Trainees). Practice_Credentialing_Prvide_Specialty_MH_Services.pdf Q4: Hw much time may be claimed fr scring and write-up f the CANS/ANSA? A4: The initial CANS/ANSA timeframe is expected t be between minutes. Updates t the initial CANS/ANS are expected t take between minutes. (One may use the ptin t cpy the riginal and then mdify fr the revised in the CANS/ANSA in the Objective Arts Database.) CANS Resurces: Page8

10 V. Claiming SMHS Q1. What are the Specialty Mental Health Services that are eligible fr Medi-Cal reimbursement? A1. Specialty Mental Health Services include: Rehabilitative Mental Health Services, which include: mental health services, medicatin supprt services, day treatment intensive, day rehabilitatin, crisis interventin, crisis stabilizatin, adult residential treatment services, crisis residential services, psychiatric health facility services case management brkerage psychiatric inpatient hspital services psychiatrist services psychlgist services EPSDT Supplemental Specialty Mental Health Services Q2. Des staff claim travel and dcumentatin time at whatever service functin rate, e.g., Mental Health Service (MHS), Case Management, etc., f the service prvided? A2. Yes. Travel and dcumentatin time must be linked t the service prvided. Q3. Can staff claim Medi-Cal fr case management services prvided while a beneficiary is in an IMD? A3. FFP cannt be claimed if the beneficiary is between the ages f Yes, if the beneficiary is 65 r lder. Yes, if the beneficiary is under 21 and is a patient in a hspital r anther accredited facility. Fllw the specific restrictins indicated fr each specific institutin (r MH service) as indicated n the ACBHCS Medi-Cal (M/C) Lck-ut Grid. Q4. Can staff claim Medi-Cal fr transprting beneficiaries t mental health appintments as a specialty mental health service? A4. N. Transprtatin is nt reimbursable as a specialty mental health service. Page9

11 Q5. Can staff claim Medi-Cal fr a parenting grup that includes parents whse children have pen cases at the clinic? A5. Yes, if the services are directed at the mental health needs f the children, rather than based upn the needs f the parents. In additin, there must be dcumentatin in the child s chart t shw the need fr this activity. Q6. Hw shuld time be divided when clients and their parents are seen tgether in a grup setting? Shuld the time be claimed as mental health services r cllateral? A6. Time shuld be divided equally amng the clients being represented. The time shuld be treated as if this were a grup setting cmpsed nly f the clients being represented (the parents themselves wuld nt cunt as grup members). Only the time fr clients wh are Medi-Cal-eligible may be claimed as a Medi-Cal service. Fr example, a staff meets with three Medi-Cal-eligible clients, five parents f these three clients, and tw parents f ne Medi-Cal-eligible client wh was nt present fr a ttal f ten peple in a grup setting fr 120 minutes. Since fur beneficiaries were represented, the time is divided by fur, and 30 minutes is claimed fr each client. If there were an additinal client wh was nt Medi-Cal eligible and that client's parents, the time wuld be divided by five, and 24 minutes wuld be claimed fr each Medi-Cal eligible client. Q7. When a treatment grup cntains bth Medi-Cal and nn Medi-Cal clients, hw is staff t divide the time? Fr example, if a grup f six clients cntaining three Medi-Cal and three nn-medi-cal clients lasts 120 minutes (grup time plus dcumentatin), hw is the time divided? By three, r by six? A7. If a prvider is delivering services t a grup cmpsed f bth Medi-Cal and nn-medi-cal eligible individuals, and the rate is the same, the prvider wuld prrate his r her time fr all (6 in abve example) individuals wh participated. Q8. Can Medi-Cal be claimed fr assisting beneficiaries t btain their medicatin by preparing an authrizatin request? A8. Yes, Medi-Cal can be claimed fr cmpleting an authrizatin request fr a prescriptin as it relates t the prvisin f medicatin supprt services. Only physicians, Nurse Practitiners, Physician Assistants, RNs, LVNs, psychiatric technicians, r pharmacists within their scpes f practice may prvide medicatin supprt services. Q9. Can staff claim Medi-Cal fr phtcpying, faxing, and ther clerical type activities as specialty mental health services? Page10

12 A9. N. Q10. Can staff claim Medi-Cal fr payee related activities? A10. Medi-Cal cannt be claimed fr time spent perfrming the fiscal respnsibilities f a payee. Fr example, staff cannt claim Medi-Cal fr time spent writing checks t pay the beneficiary s bills. Hwever, it is pssible t claim fr payee related services when such activities are necessary t address impairment in an imprtant area f life functining. Fr example, staff can claim Medi-Cal fr time spent prviding training n mney management skills. Q11. Can staff claim Medi-Cal fr telephne assessments? A11. Yes. Assessments can be cmpleted face-t-face r ver the telephne. Hwever, prviders are strngly encuraged t cmplete face-t-face assessments when determining medical necessity. Q12. Hw lng can staff claim Medi-Cal fr services prvided after a beneficiary has died? A12. All services claimed t Medi-Cal n behalf f a beneficiary must be prvided t meet the mental health needs f that beneficiary. Therefre, Medi-Cal cannt be claimed fr any services prvided nce the beneficiary has died. In additin, claims must be submitted in a timely fashin as specified in Title 9. Q13. Can staff claim Medi-Cal fr curt related assessments, e.g., cnservatrship investigatins? A13. N, if the assessment is cmpleted per request f the curt fr a purpse ther than determining medical necessity fr Medi-Cal. Fr example, Medi-Cal cannt be claimed if a curt-rdered assessment is narrwly defined fr establishment f cnservatrship and the MHP limits its assessment t this purpse. Q14. What are the current 24-hur claiming limitatins listed by service type? A14. Califrnia Cde f Regulatins (CCR), Title 9, Chapter 11, Sectin (b) specifies: "The maximum amunt claimable fr Crisis Psychtherapy (aka Crisis Interventin) in a 24-hur perid is 8 hurs." CCR, Title 9, Chapter 11, Sectin (c) specifies: "The maximum number f hurs claimable fr Crisis Stabilizatin in a 24-hur perid is 20 hurs." CCR, Title 9, Chapter 11, Sectin specifies: "The maximum amunt claimable fr Medicatin Supprt Services in a 24-hur perid is 4 hurs." Page11

13 Q15. Regarding medicatin supprt services, can staff claim Medi-Cal fr medicatin supprt services in a grup setting as lng as the fllwing cnditins are met: Time is prrated per CCR, Title 9, Chapter 11, Sectin (a)(2), and The medicatin supprt services prvided meets the definitin f medicatin supprt services in CCR, Title 9, Chapter 11, Sectin , and The service is prvided by staff wh are qualified t prvide such services? A15. Yes, as in the fllwing example: An R.N. facilitates a weekly grup discussin n medicatin educatin, e.g., the side effects f the medicatin, vercming resistance t taking medicatins, etc. This interventin and its gals shuld be addressed in each individual's client plan. Q16. Are there any special lckuts n claiming Medi-Cal while a beneficiary is in Rate Classificatin Level (RCL) facilities (grup hmes that specialize in serving children with mental illness)? A16. There are n special lckuts utside thse listed in Title 9 (except fr ICC/IHBS services) while a beneficiary resides in RCL facilities because the RCL rates d nt include treatment services. The duplicate payment issues that exist when a beneficiary is in a 24-hur facility that is receiving reimbursement fr treatment services d nt exist when the beneficiary is in an RCL facility. Q17. Can Medi-Cal be claimed fr travel time frm ne prvider site t anther prvider site? Hw abut frm a staff persn s residence t a prvider site, r frm a staff s hme t a client s hme? A17. T claim Medi-Cal, travel time must be frm a prvider site t an ff-site lcatin(s) where Medi-Cal specialty mental health services are delivered. Therefre, Medi-Cal cannt be claimed fr travel between prvider sites r frm a staff member s residence t a prvider site. NOTE: A "prvider site" is defined as a site with a prvider number, including affiliated satellite and schl site peratins. Q18. Hw lng and what types f services can be claimed t Medi-Cal prir t a determinatin f medical necessity? A18. In an urgent, crisis, r emergency situatin, the MHP can/shuld prvide whatever services are needed prir t establishing that all medical necessity criteria are met. If nt an urgent, crisis, r emergency situatin, the MHP shuld nly claim thse assessment services necessary t establish medical necessity. Page12

14 Alameda has established a maximum 30 day intake perid (frm the Episde Opening Date EOD) during which time the prvider is t establish medical necessity and cmplete the MH Assessment with Diagnsis (unless ther specified timeframe in the ACBHCS Clinical Dcumentatin Manual). Up t 60 days (frm EOD) is allwed t set up the client plan, and crdinate the arrangement f necessary services (unless ther specified timeframe in the ACBHCS Clinical Dcumentatin Manual). Hwever, the intake perid is nt exempt frm the medical necessity requirements fr claiming Medi-Cal (fr example nce it is determined that there is nt an Included Diagnsis r any ther aspect f Medi- Cal medical necessity is nt met there may be n further claiming, even fr MH Assessment r Plan Develpment). Q19. Hw des staff claim time when services with tw different rates are prvided during the curse f a client sessin, e.g., 30 minutes f mental health services and 30 minutes f case management? Des the staff claim the whle time t the dminant service prvided, r claims 30 minutes t mental health services and 30 minutes t case management? Can staff write ne prgress nte and break ut the claim by each service, r must a separate prgress nte be written fr each service? A19. In the abve situatin, staff shuld claim fr each service separately r claim the entire time t the lwer cst center, e.g., case management. Staff may write tw separate prgress ntes r write ne prgress nte that clearly delineates the time spent prviding each service. Example One: One nte fr 60 Case Management written and claimed with delineatin in bdy f PN that 30 was spent n MH Services (such as Individual Therapy) and 30 was spent f Case Management. Example Tw: Tw ntes written and claimed. One fr 30 Case Management and ne nte fr 30 MH Service (such as Ind Therapy). Q20. When can Medi-Cal be claimed fr treating undcumented individuals? A20. The MHP needs t deliver services t beneficiaries wh are undcumented individuals based n what is cvered by the beneficiaries aid categry. Undcumented individuals are eligible fr aid categries that cver emergency and/r pregnancy services nly. Title 9, Califrnia Cde f Regulatins (CCR), Sectin says: "'Emergency Psychiatric Cnditin' means a cnditin that meets the criteria in Sectin when the beneficiary with the cnditin, due t a mental disrder, is a danger t self r thers, r immediately unable t prvide fr r Page13

15 utilize, fd, shelter r clthing, and requires psychiatric inpatient hspital r psychiatric health facility services." What this means is that nly emergency psychiatric inpatient hspital services and related psychiatric inpatient hspital prfessinal services are cvered fr Medi- Cal beneficiaries wh are nly cvered fr emergency services. Crisis interventin and crisis stabilizatin are nt emergency services under the Medi-Cal managed mental health care prgram. Pregnancy-related services, when cvered, are brader than emergency services. These services invlve treatment f a mental illness that might affect the utcme f the pregnancy. A Prvider s cntract may include the prvisin f nn-medi-cal services t undcumented individuals, r thers withut Medi-Cal. Q21. If a patient is admitted t an acute care setting fr a medical cnditin, what specialty mental health services are eligible fr Medi-Cal? A21. CCR, Title 9, Sectin and Sectins thrugh nly address lck-ut requirements fr specialty mental health services. There is nthing in the regulatins that prhibits claiming Medi-Cal fr the prvisin f medically necessary specialty mental health services while a beneficiary is n a medical unit. See ACBHCS Medi-Cal Lck-ut Grid. Q22. Can Medi-Cal be claimed fr administrative hspital days if Medi-Cal was nt claimed fr the days f acute status? Fr example, a patient wh therwise meets medical necessity criteria but is ineligible fr Medi-Cal because f his/her legal status, e.g., in jail custdy. The curt later releases him/her, but the patient remains in the hspital pending suitable placement. A22. Yes, as lng as medical necessity fr acute psychiatric inpatient hspital services had been established at sme pint during the patient s stay in the hspital and the administrative days meet criteria specified in CCR, Title 9, Sectin (j)(5). Q23. What are the rules arund claiming Medi-Cal fr services prvided by students, vlunteers, and paid cnsumers? A23. Generally: 1) A "student" (aka trainee) is smene wh is in schl in a scial wrk, cunseling, r related schl placement prgram at a prvider site and includes bth undergraduate and graduate students. 2) A vlunteer is smene wh is nt "emplyed" by the prvider, fr example, a persn accumulating qualifying hurs t becme licensed, and wrks withut pay. 3) A paid Page14

16 cnsumer is smene wh is a cnsumer and wh is emplyed by the prvider, typically t prvide peer supprt and interactin t the prvider s clients. As lng as all Medi-Cal requirements and any supervisin and scpe f practice requirements are met, prviders may claim fr Medi-Cal services prvided by students, vlunteers, and paid cnsumers (all additinal prvider credentialing requirements remain the same.) See ACBHCS Medi-Cal Lck-ut Grid. Q24. What are the requirements f diagnses entered int InSyst and hw des this differ frm dcumenting the diagnses in the client s clinical recrd? A24. InSyst is part f the cunty and state s Medi-Cal billing system, diagnses entered int InSyst shuld relate t claims made t Medi-Cal. Only select mental health diagnses apprved by DHCS may be treated under Medi-Cal services and are als knwn as Included Diagnses. Only treatment fr Included diagnses may be claimed t Medi-Cal and as such nly thse diagnses are required t be inputted in t InSyst. Additinal (nn-treated) diagnses may be entered int InSyst, but sme may nt be allwed. SMHS Inpatient, SMHS Outpatient, and SUD services have different Included Diagnses lists that can be fund n the BHCS Prvider website. Prviders must use the apprpriate Included list fr their type f services. Please see the Quality Assurance sectin f the ACBHCS Prvider Website fr the M/C Included Diagnses Lists. See SMHS FAQ, Sectin I. Assessment / Diagnses Q2 fr diagnses charting requirements. Diagnses Lists and Crsswalks: 1. ACBHCS Mental Inpatient Medi-Cal Included Dx List Alpha by DSM-5 Name 2. ACBHCS DSM-IV t DSM-5 Mental Health Included Dx Crsswalk by DSM- 5 Chapters 3. ACBHS Mental Inpatient Medi-Cal Included Dx List Numeric by ICD-10 Cdes 4. ACBHCS Mental Health Outpatient Medi-Cal Included Dx List Alpha by DSM-5 Name 5. ACBHCS General Medical Cdes 6. ACBHCS Psychscial Dx List Alpha by DSM-5 Name 7. ACBHCS Psychscial Dx List Numeric By ICD-10 Cde VI. Grievances and Appeals Q1. What is the definitin f "grievance"? If there are n mre "infrmal cmplaints," what qualifies as an issue that must fllw the reslutin prcess, and Page15

17 what des nt? When des a verbal 'bad hair day' remark transitin int a verbal grievance? Hw d we decide if little gripes have t fllw a frmal grievance prcess? A1. Per Title 42, CFR, Sectin (b), grievance means an expressin f dissatisfactin abut any matter ther than an actin. If a beneficiary decides t use the MHP prcess t file a grievance, i.e., telling the designated grievance staff persn, filling ut a frm, etc. fr a minr issue then the prvider needs t fllw the grievance prcess. If the beneficiary makes a remark t a receptinist, clinician, etc., in passing, but des nt want t pursue further actin, then they are nt required t d s. Or, if a beneficiary makes a cmment directly t their clinician, r anther MHP staff persn, but just wants t "vent," that beneficiary des nt have t file a grievance with the MHP. In this example, the clinician, r ther MHP staff persn, shuld take the pprtunity t remind the beneficiary f the available prblem reslutin prcesses. VII. Infrming Materials Q1. Must prviders utilize the ACBHCS develped Infrming Materials. A1. Yes, hwever, prviders may add additinal dcuments t the Infrming Materials packet. Q2. What Scpe f Practice must staff hld in rder t explain (and answer questins regarding) the ACBHCS required Infrming Materials Packet? A2a. Any staff may explain and answer questins with the prper training, knwledge and experience fr the fllwing items in the Packet: Freedm f Chice; Explanatin f the Prvider Referral List, the Guide t Medi-Cal Mental Health Services & the BHP Member Handbk; Advance Directive Infrmatin; Beneficiary Prblem Reslutin Infrmatin; and Maintaining a Welcming & Safe Place (nt a required infrming material). The Prgress Nte must dcument this discussin and be signed by the prvider. A2b. Only staff whse Scpe f Practice includes cnducting MH Assessments may explain and answer questins regarding: Cnsent fr Services; Cnfidentiality & Privacy statement (Duty t Reprt); and the Ntice f Privacy Practices (HIPAA/HITECH). This is limited t Graduate MH Students/Trainees and (Bard Licensed, Waivered r Registered) LPHA s. As this discussin may elicit sensitive clinical cncerns (such as abuse r neglect), it must be held in a private cnfidential setting. The Prgress Nte must dcument this discussin and be signed by staff with these credentials. Page16

18 Infrming Materials Resurces: VIII. Medicare-Medi-Cal Cncurrent Billing Q1. What cnstitutes a service prvided by telephne and hw is billing cded? A1. Services prvided by telephne differ frm telemedicine services. Telemedicine benefits are Medicare reimbursable when prvided frm a clinic thrugh interactive vice and visual interface between the prvider and the client and when prvided in specific, eligible gegraphic regins. Services prvided via telemedicine shuld be claimed t Medicare prir t Medi-Cal unless anther exceptin t prir Medicare claiming exists. Specialty mental health services prvided ver the telephne are nt Medicare reimbursable and shuld be billed directly t Medi-Cal. When a service is delivered by telephne, the apprpriate place f service cde shuld be indicated as telephne. Q2. Hw is place f service "03" (Schl) defined? Q2. A facility whse primary purpse is educatin. Q3. Hw is place f service "15" (Mbile Unit) defined? A3. A facility/unit that mves frm place-t-place and equipped t prvide preventive, screening, diagnstic, and/r treatment services. Q4. Hw shuld the service activity "Plan Develpment under "Mental Health Services" be billed fr Medi-Medi claims? A4. Plan Develpment is a service activity under Mental Health Services that is nt Medicare reimbursable regardless f where it is prvided, r wh prvides it. When claiming the service activity Plan Develpment under Mental Health Services bill Medi-Cal directly fr Medi-Medi clients. Q5. Hw shuld the service activities Assessment, Therapy, and Cllateral under "Mental Health Services" be billed fr Medi-Medi claims? A5. These must be claimed t Medicare prir t Medi-Cal, unless an exceptin t Medicare billing exists (fr example, the service is prvided ver the telephne r in the cmmunity, it is prvided by a nn-medicare reimbursable prvider, r in a nn-medicare reimbursable place f service). Page17

19 IX. Scpe f Practice Q1. Regarding the AA degree referenced in Title 9, CCR, Sectin 630, defining a Mental Health Rehabilitatin Specialist, can tw years f cllege be substituted fr the AA degree? A1. Receipt f an AA degree is an abslute. Tw years f cllege cannt substitute fr it. Title 9, CCR, Sectin 630, reads: "A mental health rehabilitatin specialist shall be an individual wh has a baccalaureate degree and fur years f experience in a mental health setting as a specialist in the fields f physical restratin, scial adjustment, r vcatinal adjustment. Up t tw years f graduate prfessinal educatin may be substituted fr the experience requirement n a year-fr-year basis; up t tw years f pst-assciate arts clinical experience may be substituted fr the required educatinal experience in additin t the requirement f fur years' experience in a mental health setting." See Table #1 belw. TABLE 1: MHRS REQUIREMENTS Educatinal Degree (any subject) Experience (specialist in field f physical restratin, scial adjustment r vcatinal adjustment in a MH Setting) AA/AS 6 years BA/BS 4 years MS/MA r PhD/PsyD and nt 2 years Licensed/Waivered/Registered See ACBHCS Scpe f Practice Grid. X. Therapeutic Behaviral Services Q1. What are the qualificatins fr a TBS prvider? A1. TBS may be prvided by a Licensed Practitiner f the Healing Arts (LPHA), r staff that is under the directin f a LPHA t prvide TBS. The TBS Clinician is an LPHA and is respnsible fr the treatment plan establishing gals and is the Medi-Cal prvider. The TBS Cach is under the direct supervisin f the TBS Clinician and implements the TBS Treatment plan with the apprval/supervisin f the TBS Clinician. Q2. Where can the training infrmatin and manuals mentined in DMH Infrmatin Ntice be fund? Wh d we cntact t receive these materials and the technical assistance needed t implement the new requirements? Page18

20 A2. DMH/DHCS wrked with the Califrnia Institute fr Mental Health (CiMH) t develp the training materials mentined in DMH Infrmatin Ntice The TBS Dcumentatin Manual and the TBS Best Practices Manual are available n the website belw. In additin, subscribe t TBS infrmatin n the DMH website fr up t date details n the training materials as well as all ther TBS infrmatin. Q3. Wh can prvide Specialty Mental Health Services t children receiving TBS? A3. A prvider is defined in the Califrnia Cde f Regulatins (CCR), Title 9, and Sectin as any persn r entity wh is licensed, certified, r therwise recgnized r authrized under state law gverning the healing arts t prvide specialty mental health services and wh meets the standards fr participatin in the Medi-Cal prgram. Prviders include, but are nt limited t, licensed mental health prfessinals, clinics, hspital utpatient departments, certified day treatment facilities, certified residential treatment facilities, skilled nursing facilities, psychiatric health facilities, general acute care hspitals, and acute psychiatric hspitals that are under cntract with the MHP. Q4. Can TBS be a stand alne mental health service r des the client need t have an pen mental health case with the MHP? A4. TBS can never be a stand alne mental health service. TBS is cnsidered shrt term and supplemental t ther Specialty Mental Health Services. Specialty Mental Health Services are defined in CCR, Title 9, Sectin as rehabilitative mental health services, psychiatric inpatient hspital services, targeted case management, psychiatrist services, psychlgist services, EPSDT supplemental specialty mental health services, and psychiatric nursing facility services. Q5. Are there TBS Manuals? A5. Yes: Therapeutic Behaviral Services Crdinatin f Care Best Practices Manual /21/2010 & Therapeutic Behaviral Services (TBS) Dcumentatin Manual 2.0: T supprt the implementatin f the Curt s apprved Nine Pint Plan, the Department develped the TBS Dcumentatin Manual t guide cunties and ther key stakehlders n hw t dcument and claim TBS apprpriately. Page19

21 XI. Day Treatment [Day Rehabilitatin (DR) r Day Treatment Intensive (DTI)] Q1. Assessment windw: if a child is admitted t day treatment withut a recent assessment, is an assessment windw available t establish the service necessity, as in Crdinated Care? A1. Prviders are required t seek initial authrizatin fr day treatment services and prir authrizatin fr day treatment services that exceed five days per week. Q2. Staff available t the milieu: is this requirement met if staff is in the milieu rm but wrking individually with a child? On site (in anther rm) but wrking with ne child r awaiting a need fr their interventin? A2. Day treatment staff must be available where and when day treatment therapeutic milieu is being prvided and available t respnd t the needs f the grup. At least ne staff persn must be available t the grup in the therapeutic milieu. Staff in the milieu rm wrking with an individual beneficiary wuld be cnsidered staff available t the milieu. Staffing ratis must be maintained. Staff n site, but in anther rm wrking with ne client r waiting fr the need fr interventin wuld nt be cnsidered staff available t the milieu. If a beneficiary requires such a high degree f ne-t-ne interactin that staffing ratis are jepardized r that ther day treatment beneficiaries d nt have access t the staff, the day treatment prgram may nt be apprpriate t meet the needs f the beneficiary and ther interventins shuld be cnsidered. The prvisin f day treatment is an interactive prcess. Day treatment staff shuld nt be simply awaiting a need t intervene. Staff shuld be actively invlved the entire time the day treatment prgram is in peratin prviding therapeutic interventins t the grup. It is reasnable t anticipate that ne beneficiary might require additinal attentin at sme time; hwever, the day treatment staff shuld use the milieu envirnment t supprt the interventin. Fr example: One beneficiary habitually interferes with ther beneficiaries in a grup prcess. The day treatment staff wuld use the input f the ther grup members t identify the behavir, t identify why the behavir is prblematic and t develp interventins. Q3. Cntinuus hurs f peratin: if staff is fully integrated int a classrm during academic instructin, may the schl day hurs be cunted as part f the cntinuus hurs? If s, must staff be present in the classrm t be cunted as fully integrated? A3. The hurs f the day treatment milieu must be cntinuus and are nt tied t the hurs f the setting in which they are prvided (e.g., schl). The day treatment Page20

22 milieu may perate fr a cntinuus perid f time during the schl day, but may nt be prvided in discntinuus "blcks" f time, e.g., tw hurs in the mrning, tw hurs in the afternn and ne hur after schl. The day treatment milieu establishes the hurs f peratin and must exceed fur hurs per day fr full day prgrams and be at least three hurs per day fr half-day prgrams. In additin t required hurs f peratin, full-day prgrams require an average f three treatment hurs and half-day prgram require an average f tw treatment hurs per day in the day treatment milieu. The cmmunity meeting time is nt cunted in the required treatment hurs, but may be a part f the cntinuus hurs f peratin/therapeutic milieu r may be separate. (If the cmmunity meeting time is nt cntinuus with the therapeutic milieu, the meeting time wuld nt cunt tward the required hurs f peratin fr a full-day r half day prgram.) If day treatment is taking place in a schl setting, day treatment staff must be present during day treatment time. In cases where staff members wrk fr bth a day treatment prgram and anther prgram (e.g., schl), there must be a clear audit trail which dcuments that staff time and activities are exclusively allcated t ne prgram at a time. The staff must nly be cunted in ne staffing rati at a time, i.e., while the staff is wrking in the day treatment prgram, the staff may nt be cunted in the schl prgram staffing rati and vice-versa. See Table 2 belw. Q4. Length f stay: is there any srt f expectatin abut hw lng a client culd/shuld remain in day treatment? A4. Clinical decisins and determinatins t cntinue r discntinue day treatment r any ther specialty mental health service must be based n the individual treatment needs f the beneficiary. Prviders are respnsible fr mnitring beneficiaries' prgress in day treatment t determine when client plan gals have been met and t determine when day treatment shuld be cntinued, reduced, r terminated. TABLE 2: DAY TREATMENT (DR & DTI) HOURS Type f Hurs Half Day Full Day Prgram Prgram Minimum hurs f Operatin 3 hurs > than 4 hurs (cntinuus therapeutic milieu) Minimum average daily hurs f service cmpnents (psychtherapy, prcess grups, skill building grups, and adjunctive therapies grups) must be made available 2 hurs 3 hurs Page21

23 Q5. Minimum attendance: must a child be in the milieu fr ver 50% f the day fr billing t be allwed? Or, culd sme f the time be spent in individual services apart frm the milieu but nt separately billed, r in transitining t a mainstream classrm? A5. Beneficiaries are expected t be present in the day treatment prgram fr all scheduled hurs f peratin f the day treatment prgram. When a beneficiary is unavidably absent fr sme part f the hurs f peratin, day treatment fr an individual beneficiary will nly be reimbursed if the beneficiary is present fr at least 50% f the hurs f the scheduled hurs f that day. Individual services may be part f the day treatment prgram, prvided the minimum day treatment requirements are met fr the beneficiary. There are n exceptins t these requirements fr children being transitined t a mainstream classrm. Q6. Authrizatin: must a number f service units be requested fr authrizatin, r nly the type f service? A6. Day treatment authrizatins must address the ttal number f days fr which the service is authrized. The number f days per week as well as the length f calendar time must be specified. Authrizatins which exceed five days a week must be prir authrized by ACBHCS. Mental health services as defined in Title 9, Califrnia Cde f Regulatins (CCR), Sectin , excluding services t treat emergency and urgent cnditins and therapeutic behaviral services, prvided t a beneficiary n the same day as day treatment must be prir authrized by the MHP. ACBHCS must establish that the additinal services are medically necessary cnsidering that the beneficiary is als receiving day treatment. The authrizatin perid fr the mental health services (as defined abve) must identify when reauthrizatin, if necessary, will be required and cannt exceed the timeframes fr authrizatin f the day treatment prgram. Generally, authrizatin f the type f service and the number f units within the authrizatin perid wuld be the mst effective way t achieve these gals. ACBHCS may use alternate methds, as lng as these gals are met. Q7. Activities utside prgram hurs: hw can the required cntact with caregivers, travel, dcumentatin, etc. be distinguished frm nn-day treatment activities such as cllateral cntacts? A7. The caregiver cntact requirement specific t day treatment is fcused n the cntact being related t the beneficiary s prgress in day treatment and t supprt the rle f the caregiver in supprting the beneficiary s treatment gals. Page22

24 Dcumentatin f the cntact shuld be included in the day treatment dcumentatin. Cllateral cntacts that are nt part f day treatment must be dcumented in accrdance with the dcumentatin requirements f the specific specialty mental health service being prvided t the beneficiary. If the cllateral cntacts are delivered as mental health services that require prir authrizatin, prir authrizatin must be btained. If day treatment staff als delivers cllateral r direct services that are nt part f the day treatment prgram, the prvider must establish fiscal tracking mechanisms that maintain a clear distinctin between staff time and related resurces attributable t the day treatment prgram and staff time and related resurces attributable t ther services. Fr example, the staff may be required t reprt the actual minutes/hurs in each day spent n each type f service. Q8. Under what cnditins can classrm time be cunted twards day treatment time? A8. Academic educatinal activities cannt be cunted twards day treatment time. Q9. Desn t the authrizatin by the ACBHCS prcess usurp the rle f the IEP which, by federal and state statute, determines the services a special educatin eligible child will receive? A9. N, the authrizatin by the MHP described in the MHP Cntract relates nly t Medi-Cal payment fr Medi-Cal eligible children. The Individualized Educatin Plan (IEP) Team prcess is independent f the Medi-Cal authrizatin prcess. As lng as the IEP identifies the need fr a mental health service and cunty mental health is the apprpriate resurce and cncurs with the identified need, then cunty mental health is respnsible fr ensuring the prvisin f the identified service. Q10. What wuld be an example f a typical day f three cntinuus hurs f grup wrk fr yung kids with impulse cntrl prblems, rapid md fluctuatins, hyperactivity, and frequent need fr individual attentin r redirectin? A10. The therapeutic milieu cmpnents can be prvided while the children are engaged in varius activities, as lng as the cmpnents are made available fr the required time perid during the curse f the day treatment. Q11: Can prviders charge a fee t Medi-Cal beneficiaries fr meals served at day Page23

25 rehabilitatin r day treatment intensive prgram sites during the hurs that the prgram perates? A11: Prviders may nt bill Medi-Cal beneficiaries r their cnservatrs r therwise require Medi-Cal beneficiaries t pay a fee fr meals served during day rehabilitatin r day treatment intensive prgram hurs f peratin. XII. Client Plans Q1: When a yung child is in Fster Care, and has a Child Welfare Wrker as well as Fster parents and Bilgical parents is there sme kind f "Practice Guideline" regarding wh signs the Client Plan? A1: Since the Client Plan is nt a legal dcument and belngs t the client, the client signs the Plan. (This is different frm infrmed cnsent.) Even a yung child can shw understanding and wnership f the Plan. The child client can sign with their name, a scribble, etc. if they understand that signing it shws that the Plan belngs t them. A statement written by the clinician dcumenting why it is clinically inapprpriate t btain client s signature is sufficient, especially fr preverbal children. Hwever, if treatment includes child-parent wrk then it culd be apprpriate t btain the signature f the parent invlved in treatment. Additinally, if a clinician finds it clinically apprpriate t review the Plan with fster parents r bi parents, then their signatures can be btained, but are nt required. Page24