Mental Health Certified Family Peer Specialist (CFPS)

Transcription

1 Mental Health Certified Family Peer Specialist (CFPS) Policy Number: SC170065A1 Effective Date: May 1, 2018 Last Updated: PAYMENT POLICY HISTORY VERSION DATE ACTION / DESCRIPTION Version 1 5/1/2018 The Mental Health Certified Family Peer Specialist policy is implemented by UCare. TABLE OF CONTENTS PAGE PAYMENT POLICY HISTORY... 1 DEFINITIONS... 5 PAYMENT AND BILLING INFORMATON... 8 Covered Services... 8 Non-Covered Services... 8 Payment Decreases and Increases Impacting Mental Health Services... 9 CPT /HCPCS CODES Billing Guidelines Time Based Services RELATED PAYMENT POLICY DOCUMENTATION REFERENCES AND SOURCE DOCUMENTS Copyright 2013, Proprietary Information of UCare Page 1 of 11

2 Payment Policies assist in administering payment for UCare benefits under UCare s health benefit plans. Payment Policies are intended to serve only as a general reference resource regarding UCare s administration of health benefits and are not intended to address all issues related to payment for health care services provided to UCare members. In particular, when submitting claims, all providers must first identify member eligibility, federal and state legislation or regulatory guidance regarding claims submission, UCare provider participation agreement contract terms, and the member-specific Evidence of Coverage (EOC) or other benefit document. In the event of a conflict, these sources supersede the Payment Policies. Payment Policies are provided for informational purposes and do not constitute coding or compliance advice. Providers are responsible for submission of accurate and compliant claims. In addition to Payment Policies, UCare also uses tools developed by third parties, such as the Current Procedural Terminology (CPT *), InterQual guidelines, Centers for Medicare and Medicaid Services (CMS), the Minnesota Department of Human Services (DHS), or other coding guidelines, to assist in administering health benefits. References to CPT or other sources in UCare Payment Policies are for definitional purposes only and do not imply any right to payment. Other UCare Policies and Coverage Determination Guidelines may also apply. UCare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary and to administer payments in a manner other than as described by UCare Payment Policies when necessitated by operational considerations. *CPT is a registered trademark of the American Medical Association Copyright 2013, Proprietary Information of UCare Page 2 of 11

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4 PAYMENT POLICY OVERVIEW PRODUCT SUMMARY This Policy applies to the following UCare products: UCare Connect (Special Needs Basic Care SNBC) Prepaid Medical Assistance Program (PMAP) MinnesotaCare PROVIDER SUMMARY Certified family peer specialists are employed by existing mental health community providers or mental health centers. A certified family peer specialist must be supervised and meet all of the following qualifications: Be at least twenty-one (21) years of age; Have a high school diploma or its equivalent; Have raised or are currently raising a child with a mental illness; Currently navigating or have experience navigating the children's mental health system; Demonstrate leadership and advocacy skills; Have strong dedication to family-driven and family-focused services; and Successfully completed the DHS-approved Certified Family Peer Specialist Training and certification exam. POLICY STATEMENT Mental Health Certified Family Peer Specialist services provide family members of children or youth who have an emotional disturbance and are receiving mental health services with the tools necessary to support the treatment goals of the patient. This policy outlines the billing and payment guidelines associated with CFPS. Copyright 2013, Proprietary Information of UCare Page 4 of 11

5 PATIENT ELIGIBILITY CRITERIA In order for services to be covered by UCare the patient must meet the following: Be actively enrolled in an UCare Connect, PMAP, or MinnesotaCare product; Be between 0-21 years old ; Have a diagnosis of mental illness determined by a diagnostic assessment Children under eighteen(18) years old must be diagnosed with an emotional disturbance (ED) or meet severe emotional disturbance (SED) criteria; Young adults between the ages of 18 through 20 years old must diagnosed with mental illness or meet serious and persistent mental illness (SPMI) criteria; Have a need for mental health services as documented by information in a diagnostic assessment; and Have an individual treatment plan (ITP) that clearly documents the medical necessity Mental Health Family Peer Specialist services. DEFINITIONS TERM Diagnostic Assessment Emotional Disturbance Individual Treatment Plan (ITP) NARRATIVE DESCRIPTION Means functional face-to-face evaluation resulting in a complete written assessment that includes clinical considerations and severity of the client's general physical, developmental, family, social, psychiatric, and psychological history and current condition. The Diagnostic Assessment will also note strengths, vulnerabilities, and needed mental health services. Means a child with an organic disorder of the brain, or a clinically significant disorder of thought, mood, perception, orientation, memory, or behavior that seriously limit s a child s ability to function in primary aspects of daily living, including, but not limited to personal relations, living arrangements, work, school, and recreation. Means the person-centered process that focuses on developing a written plan that defines the course of treatment for the patient. The plan is focused on collaboratively determining real-life outcomes with a patient and developing a strategy to achieve those outcomes. The plan establishes goals, measurable objectives, target dates for achieving specific goals, identifies key participants in the process, and the responsible party for each treatment component. In addition, the plan outlines the recommended services based on the patient s diagnostic assessment and other patient specific data needed to aid the patient in Copyright 2013, Proprietary Information of UCare Page 5 of 11

6 DEFINITIONS TERM Mental Health Certified Family Peer Specialist (CFPS) Mental Health Professional Notification Prior Authorization Severe Emotional Disturbance NARRATIVE DESCRIPTION their recovery and enhance resiliency. An individual treatment plan should be completed before mental health service delivery begins. Means an individual who works with the family of a child or youth who have an emotional disturbance or a severe emotional disturbance and is receiving mental health treatment to promote the resiliency and recovery of the child or youth. They provide non-clinical family peer support building on the strengths of the family and help them to achieve desired outcomes. CFPS services provide the family with skills, knowledge and support to strengthen the family and increase parents ability to support the treatment goals of the patient and thereby enhance the ability to function better within the home, school and community and to progress with recovery and improve resiliency. These services are: Person-centered Focused on recovery and resiliency Self-directed, where possible Means one of the following: Clinical Nurse Specialist Licensed Independent Clinical Social Worker (LICSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Clinical Counselor (LPCC) Licensed Psychologist (LP) Mental Health Rehabilitative Professional Psychiatric Nurse Practitioner (NP) Psychiatry or an Osteopathic physician Tribal certified professionals Means the process of informing UCare or their delegates of a specific medical treatment or service prior to billing for certain services. Services that require notification are not subject to review for medical necessity, but must be medically necessary and covered within the member s benefit set. If claims are submitted to UCare and no notification has been received from the provider the claim will be denied. Means an approval by UCare or their delegates prior to the delivery of a specific service or treatment. Prior authorization requests require a clinical review by qualified, appropriate professionals to determine if the service or treatment is medically necessary. UCare requires certain services to be authorized before services begin. Services provided without an authorization will be denied. Means a child with emotional disturbance that meets at least one of the following criteria: Copyright 2013, Proprietary Information of UCare Page 6 of 11

7 DEFINITIONS TERM NARRATIVE DESCRIPTION Has been admitted to inpatient or residential treatment within the last three years or is at risk of being admitted Is a Minnesota resident and receiving inpatient or residential treatment for an emotional disturbance through the interstate compact Has been determined by a mental health professional to meet one of the following criteria: o Has psychosis or clinical depression o Is at risk of harming self or others as a result of emotional disturbance o Has psychopathological symptoms as a result of being a victim of physical or sexual abuse or psychic trauma within the past year o Has a significantly impaired home, school or community functioning lasting at least one year or presents a risk of lasting at least one year, as a result of emotional disturbance, as determined by a mental health professional. MODIFIERS The modifiers listed below are not intended to be a comprehensive list of all modifiers. Instead, the modifiers that are listed are those that must be appended to the CPT / HCPCS codes listed below. Based on the service(s) provided and the circumstances surrounding those services it may, based on correct coding, be appropriate to append an additional modifier(s) to the CPT / HCPCS code. When a service requires multiple modifiers the modifiers must be submitted in the order listed below. If it is necessary to add additional modifiers they should be added after the modifiers listed below. MODIFIER NARRATIVE DESCRIPTION HA HQ Child or Adolescent Group Modality Copyright 2013, Proprietary Information of UCare Page 7 of 11

8 CPT / HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION H0038 HA Certified family peer specialist services H0038 HA HQ Certified family peer specialist services in a group setting. PAYMENT AND BILLING INFORMATON Covered Services The following activities are covered as CFPS services: Education and skill building to parents and caregivers that teach them to: o Recognize their child s behavior as a result of mental illness o Develop coping skills for parenting a child with a mental illness o Develop problem solving skills in order for the child to make progress towards the individual treatment plan o Connect with community resources o Teach strategies and services that help parents to identify family strengths, promote resiliency, and develop natural supports Provide support and help parents to: o Learn how best to advocate for culturally appropriate services o Link to other parents for mutual support Non-Covered Services The following services are not covered as CFPS services: Transportation Services that are performed by volunteers Household tasks, chores or related activities including, but not limited to laundering clothes, moving, housekeeping and grocery shopping Time spent on call and not delivering services to patients On-the-job training or other job-specific skills services Copyright 2013, Proprietary Information of UCare Page 8 of 11

9 Case management Outreach to potential patients Services furnished to family members Room and board Services furnished by providers that are not approved to provide CFPS services CFPS services that are included in the daily rate may not be billed separately PROVIDER PAYMENT POLICY Payment Decreases and Increases Impacting Mental Health Services Based on MHCP guidelines when certain mental services are furnished by a Master s level provider a twenty percent (20%) reduction is applied to the allowed amount. Master s level providers are: Clinical Nurse Specialist (CNS-MH) Licensed Independent Clinical Social Worker (LICSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Clinical Counselor (LPCC) Licensed Psychologist (LP) Master s Level Psychiatric Nurse Practitioner Master s Level enrolled provider UCare follows MHCP guidelines when applying Master s level provider reductions to eligible mental health services. Impacted services are identified by indicator (a) in the DHS MH Procedure CPT or HCPC Codes and Rates Chart. A link to this chart is available in the References and Sources section of this Policy. Master s level provider reductions are not applied to mental health services when they are furnished in a Community Mental Health Center (CMHC). In addition to the Master s level provider reduction, UCare also applies a 23.7% increase to mental health services identified with a b in the DHS MH Procedure CPT or HCPC Codes and Rates Chart. A link to this chart is available in the References and Sources section of this Policy. This increase is applied to behavioral health services when performed by: Psychiatrists; Advance Practice Nurses; o Clinical Nurse Specialist o Nurse Practitioner Community Mental Health Centers; Copyright 2013, Proprietary Information of UCare Page 9 of 11

10 Mental health clinics and centers certified under Rule 29 and designated by the Minnesota Department of Mental Health as an essential community provider; Hospital outpatient psychiatric departments designated by the Minnesota Department of Mental Health as an essential community provider; and Children s Therapeutic Services and Supports (CTSS) providers for services identified as CTSS in the DHS mental health procedure CPT or HCPCs codes and rates chart. UCare will utilize the above-referenced MHCP chart to determine whether the decrease to Master s level providers or a Mental Health Practitioner working as a clinical trainee should be applied, and/or determine if the 23.7% legislative increase will be applied to behavioral health services. If there is a discrepancy between how DHS adjudicates claims and the chart published in the MHCP provider manual, UCare will adjudicate claims based on the chart published by DHS. When DHS updates the published chart, UCare will update payment requirements within forty (40) business days of receipt of the change. Claims previously paid will not be adjusted. Additional information regarding UCare fee schedule updates can be found in the UCare Provider Manual (Section 10-20, Fee Schedule Updates). The grid below identifies whether the Master s level provider reduction and/or 23.7% increase applies to service(s) associated with Mental Health Certified Family Peer Specialist. CPT /HCPCS CODES CPT or HCPCS CODES MODIFIER NARRATIVE DESCRIPTION UNIT OF SERVICE H0038 HA Certified family peer specialist services H0038 HA, HQ Certified family peer specialist services in a group setting. APPLY MASTER S LEVEL REDUCTION DOES 23.7% INCREASE APPLY PROVIDERS ELIGIBLE TO PERFORM SERVICE 15 Minutes No No Certified Family Peer Specialist 15 Minutes No No Certified Family Peer Specialist In the event that other government-based adjustments are required, UCare will implement those changes that apply to managed care organizations. The impact will be reflected in the providers final payment. When DHS updates the published list of impacted services / fee schedule, UCare will update payment requirements within forty (40) business days of receipt of the change. Claims previously paid will not be adjusted. Additional information regarding UCare fee schedule updates can be found in the UCare Provider Manual (Section 10-20, Fee Schedule Updates). Billing Guidelines CFPS services should be submitted using the MN-ITS 837P format or the electronic equivalent. Copyright 2013, Proprietary Information of UCare Page 10 of 11

11 Time Based Services When billing for services that include time as part of their definition, follow HCPCS and CPT guidelines to determine the appropriate unit(s) of service to report. Based on current guidelines, providers must spend more than half the time of a time-based code performing the service to report the code. If the time spent results in more than one and one half times the defined value of the code, and no additional time increment code exists, round up to the next whole number. Outlined below are the billable units minutes or 60 minutes: MINUTES BILLABLE UNITS Fifteen (15) Minute Increments 0 7 minutes 0 (no billable unit of service) 8 15 minutes 1 (unit of billable service) Sixty (60) Minute Increments 0 30 minutes 0 (no billable unit of service) minutes 1 (unit of billable service) PRIOR AUTHORIZATION, NOTIFICATION AND THRESHOLD LIMITS UCare s prior authorization and/or notification requirements and threshold limits may be updated from time to time. The most current information can be found here. RELATED PAYMENT POLICY DOCUMENTATION REFERENCES TO OTHER PAYMENT POLICY DOCUMENTATION THAT MAY BE RELEVANT TO THIS POLICY. POLICY NUMBER SC14P0004A1 POLICY DESCRIPTION AND LINK Diagnostic Assessment REFERENCES AND SOURCE DOCUMENTS LINKS TO CMS, MHP, MINNESOTA STATUTE AND OTHER RELEVANT DOCUMENTS USED TO CREATE THIS POLICY. DHS MH Procedure CPT or HCPC Codes and Rates Chart MHCP Provider Manual, Mental Health Services, Mental Health Certified Family Peer Specialist MN Statutes 256B.0616 Mental Health Certified Family Peer Specialist Minnesota Rules , Subpart 1, A and B, or C, or E Copyright 2013, Proprietary Information of UCare Page 11 of 11