MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ISSUE DATE EFFECTIVE DATE NUMBER September 8, 1995 September 8, 1995 1153-95-01 SUBJECT Accessing Outpatient Wraparound Mental Health Services Not Currently Included n the Medical Assistance Program Fee Schedule for Eligible Children Under 21Years of Age Darlene C. Collins, M.Ed., M.P.H Deputy Secretary for Medical Assistance Programs PURPOSE: The purpose of this Bulletin is to inform providers of the requirements and procedures necessary to receive medical assistance reimbursement for medically necessary outpatient wraparound mental health services currently not on the Medical Assistance Program Fee Schedule for individuals under 21 years of age with a diagnosed mental illness or emotional disturbance, regardless of any additional diagnosis such as substance abuse or mental retardation. The requirements and procedures described in this Bulletin apply to every child eligible for Medical Assistance, whether that child is living with a natural parent, a foster parent, or in some setting other than a residential treatment facility as described in Medical Assistance Bulletin 01-95-12, 11-95-08, 12-95-04, 13-95-01, 17-95-05, 41-95-03, 50-95-03, 53-95-01, and Medical Assistance Bulletin 1165-95-01. The procedures described in this Bulletin apply to children served by fee-for-service providers, or enrolled in HealthPASS. Managed care programs other than HealthPASS provide these mental health services directly to children enrolled in those programs. Requests for services are to be made through the health-maintenance organization or other managed care program according to each organization's normal procedures. In addition, the requirements that mental health services must be recommended by a county interagency team and provided consistent with Pennsylvania's Child and Adolescent Services System Program (CASSP) principles (see Attachment 1) apply to mental' health services provided by each managed care program. SCOPE: Base Service Units County CASSP Coordinators County MH/MR Program Administrators County Children & Youth Administrators Juvenile Court Judges Commission Psychiatric Outpatient Clinics Psychiatric Partial Hospitalization Programs *01-95-11, 17-95-04, 29-95-02, 33-95-03, 41-95-02, 48-95-02, 50-95-02. COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Call the appropriate toll-free number for your provider type. DISTRIBUTION: *See Above
-2- Family-Based Mental Health Services Pennsylvania County Commissioner's Association Pennsylvania Community Provider's Associations Parents Involved Network Physicians Psychologists Medical Assistance Managed Care Plans and Subcontractors BACKGROUND: In 1989, Congress amended the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provisions of the federal' Medicaid statute to require states to provide "necessary health care, diagnostic services, treatment, and other measures described in [the statute] to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan." 42 U.S.C. 1396d(r) (5) ("OBRA '89") (emphasis added), Therefore, individuals under age 21 with emotional disturbances or mental illnesses may be eligible for a wide range of mental health services to assist families to care for their children and adolescents at home and in their communities as alternatives to the more restrictive residential and psychiatric inpatient services. Consistent with the OBRA '89 requirements, the Office of Medical Assistance Programs (OMAP) is issuing the following guidelines, whereby medically necessary outpatient wraparound mental health services or health-related services are eligible for Medical Assistance (MA) reimbursement, when provided to eligible individuals, whether or not those services are listed in the Medical Assistance Program Fee Schedule or otherwise covered in the State Medicaid Plan, as long as the services are authorized under the federal Medicaid statute. These guidelines apply both to services not on the fee schedule and to traditional "amount, duration, and scope" limits as set forth in the State Medicaid Plan. The following requirements and procedures were developed using a coordinated approach to mental health services for children in concert with the County Mental Health/Mental Retardation (MH/MR) Administrators, County Children and Youth (CCY) Administrators, Chief Juvenile Probation Officers, providers, advocates and families, and based on Pennsylvania's Child and Adolescent Service System Program (CASSP) (see Attachment 1) to facilitate a recipient's access to medically necessary mental health services.
-3- This Bulletin supersedes MA Bulletin Number 01-93-03, 29-93-02, 33-93-02, 41-93-01, 48-93-01 which provided interim requirements and procedures to access mental health services not included on the fee schedule. PLEASE NOTE: Mental health services currently listed on the Medical Assistance Program Fee Schedule and in Medical Assistance Bulletin Number 01-94-01, 41-94-01, 48-94-01, 49-94-01, 50-94-01 will continue to be reimbursed according to the applicable provider regulations and procedures. REQUIREMENTS FOR OUTPATIENT WRAPAROUND MENTAL HEALTH SERVICES NOT INCLUDED ON THE FEE SCHEDULE. A. CLIENT ELIGIBILITY An individual under 21 years of age with an emotional disturbance or mental illness, regardless of any additional diagnosis such as substance abuse or mental retardation, is eligible when: 1. The individual is eligible for Medical Assistance; and 2. The individual has a documented need for mental health services, as prescribed or recommended as medically necessary by a licensed physician or licensed psychologist; and 3. The mental health services are recommended by a county interagency service planning team (see Attachment 2) with representation of the County MH program and, if applicable, the County C&Y Agency or Juvenile Probation program and, if applicable, the managed care program; representatives from all other community services systems currently providing service to the child and family, including the Education system; the child and the family and/or legal guardian; and the prescribing physician or psychologist when possible; and 4. The individual has received a psychological or psychiatric evaluation that supports a DSM IV diagnosis, AXIS I through V, or a ICD-9-CM along with AXIS III through V of the DSM (see attachment 3); and 5. The service has been prior authorized by OMAP.
-4- B. EXAMPLES OF REIMBURSABLE OUTPATIENT WRAPAROUND MENTAL HEALTH SERVICES "Additional outpatient wraparound mental health services are not listed in the State Medicaid Plan which may be medically necessary as rehabilitation services and which may include age- appropriate basic living skills, social skills development, counseling and therapy. The goal of these rehabilitation services is to maintain the child at home or as close to home and community as possible, in the most normalizing and age-appropriate setting in order to avoid unnecessarily restrictive or otherwise inappropriate placements. These rehabilitation services may be provided in a variety of settings, including the child s own home, day care center, school, adoptive or foster home, including a group hone, and non-secure juvenile justice placement. These rehabilitation services may be available at a variety of times during the day-to-day life of a child: before or after school, during school, evenings, weekends, summertime, or holidays C. PROVIDER QUALIFICATIONS To receive MA reimbursement for these outpatient wraparound mental health services, a provider must: 1. Be licensed by OMH to provide mental health services. In the case of a school, which cannot be licensed as a provider of mental health services, staff who provide the serviceis1 must meet all the applicable regulatory and legal requirements and must provide mental health services in the same manner and similar quality as are provided by licensed mental health entities. 2. Be currently enrolled as an MA provider. An entity that provides licensed outpatient mental health services, partial hospitalization services or family-based mental health services may enroll as a Provider Type 50 by completing an enrollment form and receiving a Medical Assistance provider number. (Information about becoming enrolled as a provider is available by calling OMAP at (717) 772-6456).
-5- A Provider Type 50 may provide the service directly, either on or off site, or may subcontract for mental health services for a child when the agency does not provide the medically necessary service, so long as the subcontracted service is prior approved by the Department (see Attachment 4 - Example Subcontract Agreement Form). The enrolled provider may subcontract with an individual or an agency not enrolled as an MA provider. Responsibility for the clinical direction of the subcontracted services, and for the qualifications of the subcontracted provider of the service, rests with the enrolled service provider. 3. Provide services consistent with the CASSP Principles for Children s Services in Pennsylvania and the prescribed treatment goals, intervention approaches and expected outcomes for the child or adolescent. D. PAYMENT FOR SERVICES - INTERIM RATE SETTING PROCESS The Department will, on an interim basis, establish a negotiated payment rate for these prescribed outpatient wraparound mental health services as follows: 1. The payment rate for medically necessary mental health services that are not published on the Medical Assistance Program Fee Schedule will be established on an individualized basis. 2. The payment rate for medically necessary mental health services that are published on the Medical Assistance Fee Schedule but are unavailable at the published MA rate will be established on an individualized basis. The payment rate can be established on a facility- wide basis if the facility presents the required documentation that the service is not available at the MA rate on a facility-wide basis. For facilities with multiple sites, the established payment rate will be site specific and will not automatically extend to all other facility sites. The Department expects to issue rate setting guidelines during the 1995-1996 Fiscal year.
-6- PROCEDURES FOR OUTPATIENT WRAPAROUND MENTAL HEALTH SERVICES A. PROGRAM EXCEPTIONS 1. To request prior approval of MA payment for outpatient wraparound mental health services not on the Medical Assistance Program Fee Schedule, exceptions to the regulatory limits on amount, duration and scope of services that are on the Fee Schedule, or exceptions to the Fee Schedule rate, the following forms and information must be prepared: a. The Outpatient Services Authorization Request (MA 97) signed by the prescribing licensed physician or licensed psychologist or designee (see Attachment 5) ; REMINDER: Be sure to check the 1150 Waiver block (number 2) on the form. b. A copy of the most recent psychiatric or psychological evaluation (within 45 days of submission) signed by the prescribing licensed physician or licensed psychologist, which includes a recommendation for the requested mental health services; c. A copy of the individual's current or proposed mental health treatment plan developed by the interagency treatment team, which specifies the goals of treatment, describes the requested service(s), including service activities and staff qualifications, and specifically identifies how the requested service(s) will achieve the treatment goals and expected outcomes; Requests for continuation of outpatient wraparound mental health treatment services must contain documentation that identifies the current services the child and family are receiving; how the child and family are benefiting from these services; the medical necessity to continue services; and the expected outcomes and benefits the child and family will receive if the Department approves a continuation of the services; d. The Plan of Care Summary (see Attachment 6).
-7-2. When requesting prior approval of payment for services not on the Fee Schedule and not already approved by the Department (for example, therapeutic recreation services), the following documentation must also be prepared: a. A service description; b. The proposed rate for the service being requested; c. A budget that justifies the proposed rate To be eligible for consideration, each service description must contain all of the information and follow the format as set forth in the Service Description Format (see Attachment 7). Any service description that does not contain all of the information in the order specified will automatically be rejected by the Department. Written notification of the decision to approve or reject a service description and the rate will be sent to the provider no later than the 45th day after receipt of this information by the Department, except as set forth in the following paragraph. If the Department fails to send a response by the 45th day, the request will be deemed approved until the service description is formally approved or rejected. The 45-day period for formal response by the Department will be stayed if, within that time, the Department requests additional information by letter or facsimile- In such a case, the Department will impose a specific deadline by which the provider must submit the additional information. If the provider does not submit the requested information on or before the specified due date, the Department will disapprove the service description. Upon receiving the additional information, the Department will date stamp the supplemental package and make a decision to approve or reject the service description within a total of 55 days (including the time that elapsed before the Department requested supplemental information). If the Department
-8- does not send a response by the 55th day, the service description will be deemed approved until it is formally approved or rejected. 3. When requesting an exception to the Fee Schedule rate, the following documentation must also be prepared: a. Information from three providers to support the claim that the service is unavailable at the amount of the MA fee and their fees for the service; b. The names, addresses and phone numbers of the three providers who were contacted; and c. The proposed rate for the service being requested. NOTE: A facility or specific facility site may request a facility-wide or facility site-wide exception to a Fee Schedule rate. If the request is approved, the facility or site must include a copy of the written notification of approval with each request for prior approval of mental health services for each child. Written notification of the decision to approve or reject will be sent to the facility or site no later than the 21st day after receipt of the request by the Department or the request will be deemed approved. 4. The request for prior approval, and all supporting documentation, must be forwarded to: a. Original Office of medical Assistance Programs 1150 Administrative Waiver Office PO Box 8044 Harrisburg, PA 1710 b. Copy Administrator of the local County MH/MR Office and, if applicable, the County C&Y Agency.
-9-5. The above information and all supporting documentation must be submitted as soon as possible after the determination is made that outpatient wraparound mental health services are necessary. a. The request will be date stamped upon receipt by the Department. A decision to approve or reject the request will be made within 21 days of receipt of a correctly completed package or the request will be deemed approved. OMAP will conduct a second review of every request for prior approval in which the initial review indicates that the request should be rejected because the service is not medically necessary. This second review will be conducted by the Department's medical consultant. This second review will not delay the decision or extend the 21-day period permitted for such decisions. NOTE: If a managed care plan tentatively determines that a requested service is not medically necessary, the Plan will submit the request to the Department for review by the medical consultant and will abide by the decision rendered by the consultant. Such review will not extend the 21-day period for final decision. b. Written notification of the decision will be sent to the service provider, prescribing physician or psychologist, the County MH/MR Office, and, if applicable, the County C&Y Agency or Juvenile Probation Office, the child's case manager, and the child's parent (s) or legal guardian(s) no later than the 21st day after receipt of the request. c. The child or child's parent(s) or legal guardian(s) will also receive notice of the right to appeal a denial of the service. d. OMAP staff may contact the County MH/MR Office and, if applicable, the County C&Y Agency or Juvenile Probation Office, and the prescribing physician or psychologist to obtain additional pertinent information within the 21-day period.
-10- e. If the Outpatient Service Authorization Request (MA 97) and the supporting documentation are incomplete, OMAP staff will contact the prescribing physician, psychologist or designee by telephone or facsimile within 18 days from receipt of the request. If the child is in the custody of the County C&Y agency and the additional information and/or corrections are administrative rather than medical, OMAP staff will contact the child's assigned case manager instead of the physician, psychologist, or designee. OMAP staff will identify the additional information and/or corrections needed to process the request and will establish a deadline for submission. This telephone or facsimile contact stops the 21-day time period for an 0MAP response to the request. OMAP will date stamp the additional information and/or corrections upon receipt and a decision to approve or reject will be made within 16 days of receipt of the additional information or the request will be deemed approved. If the prescribing physician, psychologist, designee or, if applicable, the child's case manager fails to submit the additional information and/or corrections by the established deadline, the original request will be denied. 6. Expedited Review Process - There may be a situation when the child is at risk and the child's mental illness or emotional disorder warrants a more expeditious review of a request for outpatient wraparound mental health services. When this situation occurs: a. The prescriber must submit the proper documentation as described above to OMAP. b. At the same time, the prescriber must contact the County MH Administrator or designee to request an expedited review, and describe the child's presenting psychiatric status that warrants an expedited review.
-11- c. If the County MH Administrator or designee agrees to the need for expedited review, the County Administrator notifies the Department's OMH Area staff of the request and a decision is reached within one workday whether to approve the need for expedited review, The Area OMH staff must have a plan for phone coverage to respond to requests whenever the designated staff person is unavailable. d. If the Area OMH agrees to the need for an expedited review, the Area staff contacts OMAP by telephone on the same workday, requests an expedited review, and faxes a completed copy of the Request for Expedited Outpatient Wraparound Mental Health Services (see Attachment 81). If there is no response by either the County MH Administrator or the Area OMH staff within 2 workdays, the prescriber may contact the Area OMH staff. e. OMAP staff conducts the review within 3 working days of the request from the Area staff and documents the Area staff contact. A denial of a request for an expedited review applies only to the time frame for the review process and does not affect the decision regarding the medical necessity for the service. If the request for expedited review is denied at any level, the routine prior approval review process will still take place and the service request may be approved. 7. Emergency Review Process - There may be a situation where the child is at risk and the child's mental illness or emotional disorder warrants immediate outpatient wraparound mental health services. When this situation occurs and the prescribed services are not on the Fee Schedule, or exceed the Fee Schedule limits on amount, duration, and scope, or cannot be secured at the Fee Schedule rate, the prescriber may request an emergency review. a. The following information must be provided to the OMH Bureau of Children's Services:
-12- - Description of the individual's presenting psychiatric status and severity of the symptoms as evaluated by the treating physician or psychologist; - Documentation of a DSM IV mental health diagnosis, Axis I through V, or an ICD-9-CM diagnosis along with AXIS III through V of the DSM IV; - Recommendation for the specific service by a physician or licensed psychologist. b. The documentation may be submitted by telephone, (717) 787-3458, during work hours, 8:30 A.M. to 5:00 P.M., and must be submitted by facsimile, (717) 787-2828, within the next work day to the OMH Bureau of Children's Services. The Department will not provide reimbursement if the information in paragraph 7.a. is incomplete or not submitted by facsimile within one work day. c. The Bureau of Children's Services will make a "same day" determination that the criteria for medical necessity has or has not' been met. Authorization for reimbursement for the services will be effective on the date the service was initiated. The provider of service will be notified verbally and in writing of the approval or disapproval of the request for emergency services. d. Emergency services will be approved for a ten-day period, and a request for an expedited review of continued services should be initiated within the ten-day period. If a request for a second period of ten days is needed, information listed in paragraph 7.a. must be submitted by telephone and/or facsimile to OMH by the tenth day of the initial period. 8. If the Department denies authorization of a request for services because such services are not medically necessary, too restrictive, or inadequate for the child's needs, Area staff in OMH and, if applicable, the Regional Office of the Office of Children, Youth and Families will work with the County MH/MR Office and, if applicable,
-13- the county C&Y agency or Juvenile Probation Office, and the prescriber, and all other members of the interagency service planning team to develop an alternative mental health service plan within 30 days of receiving the denial and to ensure the implementation of the plan, The Department will reimburse those mental health services prescribed or recommended as medically necessary by the physician or psychologist, recommended by the interagency service planning team, and approved by the Department as medically necessary. 9. Reimbursement for outpatient wraparound mental health services currently not on the Fee Schedule shall be approved for no more than six months at a time. If a child is receiving outpatient wraparound mental health treatment services and a provider is requesting continuation of those services, an MA 97 and the other information listed above, documenting both the medical necessity for the continuation of outpatient wraparound mental health treatment services, and the nature of utilization of current service(s) by the child and/or family, must be submitted no later than 30 days prior to the last date of the previously approved period. Reauthorization of services is subject to the same time periods and information requirements as approval of an initial request. B. INVOICING FOR OUTPATIENT WRAPAROUND MENTAL HEALTH SERVICES Medical Assistance payment for outpatient wraparound mental health services is contingent upon the provider's receipt of the Prior Authorization Notice or Program Exception Notice. The Physician's Invoice or Medical Services/Supplies Invoice MA 319 must be used to bill for outpatient wraparound mental health services. All claims for MA covered services must be supported by documentation in the client's record, including the Prior Authorization Notice or Program Exception Notice, which meets the regulatory requirements of 55 PA Code Chapter 1101. The invoice must be submitted to: Office of Medical Assistance Programs P.O. Box 8297 Harrisburg, PA 17105 The Department will process claims within 30 days of receipt of a clean invoice.