12 Va. Admin. Code § 30-60-143 - Mental health services utilization criteria; definitions
A.
Definitions. The following words and terms when used in this section shall have
the following meanings unless the context indicates otherwise:
"Certified prescreener" means an employee of either the local community services board or behavioral health authority, or its designee, who is skilled in the assessment and treatment of mental illness and who has completed a certification program approved by the Department of Behavioral Health and Developmental Services (DBHDS).
"Certified prescreener assessment" means an assessment for crisis intervention and crisis stabilization completed by a certified prescreener that meets the elements of a comprehensive needs assessment.
"Comprehensive needs assessment" means the same as defined in 12VAC30-50-130 and also includes individuals who are older than 21 years of age.
"Emergency services" means unscheduled and sometimes scheduled crisis intervention, stabilization, acute psychiatric inpatient services, and referral assistance provided over the telephone or face-to-face if indicated, and available 24 hours a day, seven days per week.
"Licensed mental health professional" or "LMHP" means the same as defined in 12VAC30-105-20.
"LMHP-resident" or "LMHP-R" means the same as defined in 12VAC30-50-130.
"LMHP-resident in psychology" or "LMHP-RP" means the same as defined in 12VAC30-50-130.
"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as defined in 12VAC30-50-130.
"Qualified mental health professional-adult" or "QMHP-A" means the same as defined in 12VAC35-105-20.
"Qualified mental health professional-child" or "QMHP-C" means the same as defined in 12VAC30-50-130.
"Qualified mental health professional-eligible" or "QMHP-E" means the same as defined in 12VAC30-50-130.
"Qualified paraprofessional in mental health" or "QPPMH" means the same as the term is defined in 12VAC35-105-20.
B. Utilization reviews shall include
determinations that providers meet the following requirements:
1. The provider shall meet the federal and
state requirements for administrative and financial management capacity. The
provider shall obtain, prior to the delivery of services, and shall maintain
and update periodically as the Department of Medical Assistance Services (DMAS)
or its contractor requires, a current provider enrollment agreement for each
Medicaid service that the provider offers. DMAS shall not reimburse providers
who do not enter into a provider enrollment agreement for a service prior to
offering that service.
2. The
provider shall document and maintain individual case records in accordance with
state and federal requirements.
3.
The provider shall ensure eligible individuals have free choice of providers of
mental health services and other medical care under the individual service plan
(ISP).
4. Providers shall comply
with DMAS marketing requirements as set out in
12VAC30-130-2000. Providers that
DMAS determines have violated these marketing requirements shall be terminated
as a Medicaid provider pursuant to
12VAC30-130-2000
E. Providers whose contracts are terminated
shall be afforded the right of appeal pursuant to the Administrative Process
Act (§
2.2-4000 et seq. of the Code of
Virginia).
5. If an individual
receiving community mental health rehabilitative services is also receiving
case management services pursuant to
12VAC30-50-420 or
12VAC30-50-430, the provider shall
collaborate with the case manager by notifying the case manager of the
provision of community mental health rehabilitative services and sending
monthly updates on the individual's treatment status. A discharge summary shall
be sent to the care coordinator or case manager within 30 calendar days of the
discontinuation of services. Service providers and case managers who are using
the same electronic health record for the individual shall meet requirements
for delivery of the notification, monthly updates, and discharge summary upon
entry of this documentation into the electronic health record.
6. The provider shall determine who the
primary care provider is and inform the primary care provider of the
individual's receipt of community mental health rehabilitative services. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.
7. Prior to admission, an appropriate
comprehensive needs assessment shall be conducted by the LMHP, LMHP-S, LMHP-R,
or LMHP-RP. The comprehensive needs assessment shall include documented history
of the severity, intensity, and duration of mental health care problems and
issues and all of the following elements:
(i)
the presenting issue or reason for referral;
(ii) mental health history or history of
hospitalizations;
(iii) previous
interventions by providers and timeframes and response to treatment;
(iv) medical profile;
(v) developmental history, including history
of abuse, if appropriate;
(vi)
educational or vocational status;
(vii) current living situation and family
history and relationships;
(viii)
legal status;
(ix) drug and alcohol
profile;
(x) resources and
strengths;
(xi) mental status exam
and profile;
(xii) diagnosis;
(xiii) professional summary and
clinical formulation;
(xiv)
recommended care and treatment goals; and
(xv) the dated signature of the LMHP, LMHP-S,
LMHP-R, or LMHP-RP.
a. A single comprehensive
needs assessment shall be used to document the medical necessity for one or
more community mental health rehabilitative service provided by the same
DBHDS-licensed agency.
b. The
comprehensive needs assessment shall be completed face to face and signed by
the LMHP, LMHP-R, LMHP-RP, or LMHP-S; include all required elements as defined
in 12VAC30-50-130; describe how each
recommended community mental health rehabilitative service is medically
necessary; and be reviewed and updated at a minimum of annually or as the
individual's needs change.
c. The
comprehensive needs assessment shall be reviewed and updated by an LMHP,
LMHP-R, LMHP-RP, or LMHP-S within 31 days if there is a clinical indication
based on the medical, psychiatric, or behavioral symptoms of the
individual.
d. An LMHP, LMHP-R,
LMHP-RP, or LMHP-S shall conduct an annual face-to-face review and update of
the comprehensive needs assessment that includes a review of the comprehensive
needs assessment; any necessary updates to the 15 required elements of the
comprehensive needs assessment to reflect the individual's current level of
functioning; an updated description of how the individual meets medical
necessity criteria for all recommended services; and a contemporaneously dated
signature of the LMHP, LMHP-R, LMHP-RP, or LMHP-S.
e. The comprehensive needs assessment is
outdated if any of the following occurs: an LMHP, LMHP-R, LMHP-RP, or LMHP-S
has not completed the annual review and update; within the past 31 calendar
days, the provider has not provided a community mental health rehabilitative
service or a case management activity (as defined in
12VAC30-50-420 or
12VAC30-50-430) as recommended by
the comprehensive needs assessment; or, within the past 31 days, the
comprehensive needs assessment has not been updated to reflect a change in the
individual's current level of functioning.
f. If the comprehensive needs assessment is
outdated, a new comprehensive needs assessment is required prior to resuming a
community mental health rehabilitative service that lapsed for more than 31
calendar days. If the comprehensive needs update is not outdated, it must, at a
minimum, be updated to document the medical necessity for a community mental
health rehabilitative service that lapsed for more than 31 calendar
days.
g. Providers shall only bill
under the community mental health rehabilitative service assessment codes for
the initial comprehensive needs assessment and for comprehensive needs
assessments that replace an outdated assessment. Providers of multiple
community mental health rehabilitative services shall only bill one community
mental health rehabilitative service assessment code per individual.
h. Claims for services that are based upon
comprehensive needs assessments that are incomplete, outdated, or missing shall
not be reimbursed.
i. For crisis
intervention and crisis stabilization services, a certified prescreener
assessment may be used in place of the comprehensive needs
assessment.
8.
The provider shall include the individual and the family or caregiver, as may
be appropriate, in the development of the ISP. To the extent that the
individual's condition requires assistance for participation, assistance shall
be provided. The ISP shall be updated annually or as the needs and progress of
the individual changes. An ISP that is not updated either annually or as the
treatment interventions based on the needs and progress of the individual
change shall be considered outdated. An ISP that does not include all required
elements specified in
12VAC30-50-226 shall be considered
incomplete. Claims for services that are based upon ISPs that are incomplete,
outdated, or missing shall not be reimbursed. All ISPs shall be completed,
signed, and contemporaneously dated by the appropriate professional for the
service who is preparing the ISP within a maximum of 30 days of the date of the
completed assessment unless otherwise specified. A youth's ISP shall also be
signed by the parent or legal guardian and the adult individual shall sign his
own. If the individual is unwilling to sign the ISP, then the service provider
shall document the clinical or other reasons why the individual was not able or
willing to sign the ISP. Signatures shall be obtained unless there is a
clinical reason that renders the individual unable to sign the ISP.
a. Every three months, the appropriate
professional for the service shall review the ISP, modify the ISP as
appropriate, and update the ISP, and all of these activities shall occur with
the individual in a manner in which the individual may participate in the
process. The ISP shall be rewritten at least annually.
b. The goals, objectives, and strategies of
the ISP shall be updated to reflect any change in the individual's progress and
treatment needs as well as any newly identified problems.
c. Documentation of ISP review shall be added
to the individual's medical record no later than 15 days from the calendar date
of the review as evidenced by the dated signatures of the appropriate
professional for the service and the individual.
9. Progress notes shall include, at a
minimum, the name of the service rendered, the date of the service rendered,
the signature and credentials of the person who rendered the service, the
setting in which the service was rendered, and the amount of time or units or
hours required to deliver the service. The content of each progress note shall
corroborate the units or hours billed. Progress notes shall be documented for
each service that is billed.
10.
Services described in this section shall be rendered consistent with the
definitions, service limits, and requirements described in this section and in
12VAC30-50-226.
C. Day treatment or partial hospitalization
services shall be provided following a comprehensive needs assessment completed
by the LMHP, LMHP-R, LMHP-RP, or LMHP-S. An ISP, as defined in
12VAC30-50-226, shall be fully
completed, signed, and dated by either the LMHP, LMHP-R, LMHP-RP, LMHP-S,
QMHP-A, QMHP-E, or QMHP-C and reviewed or approved by the LMHP, LMHP-R,
LMHP-RP, or LMHP-S within 30 days of service initiation.
1. The enrolled provider of day treatment or
partial hospitalization shall be licensed by DBHDS as a provider of day
treatment services.
2. Services
shall only be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C,
QMHP-E, or a qualified paraprofessional under the supervision of a QMHP-A,
QMHP-C, QMHP-E, LMHP, LMHP-R, LMHP-RP, or LMHP-S.
3. The program shall operate a minimum of two
continuous hours in a 24-hour period.
4. Individuals shall be discharged from this
service when other less intensive services may achieve or maintain psychiatric
stabilization.
D.
Psychosocial rehabilitation services shall be provided to those individuals who
have experienced long-term or repeated psychiatric hospitalization, who
experience difficulty in activities of daily living and interpersonal skills,
whose support system is limited or nonexistent, or who are unable to function
in the community without intensive intervention or when long-term services are
needed to maintain the individual in the community.
1. Psychosocial rehabilitation services shall
be provided following a comprehensive needs assessment that clearly documents
the need for services. The comprehensive needs assessment shall be completed by
either an LMHP, LMHP-R, LMHP-RP, or LMHP-S. An ISP shall be completed by either
the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-E, or QMHP-C and be reviewed or
approved by either an LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days
of service initiation. At least every three months, the LMHP, LMHP-R, LMHP-RP,
LMHP-S, QMHP-A, QMHP-C, or QMHP-E must review, modify as appropriate, and
update the ISP.
2. Psychosocial
rehabilitation services of any individual that continue for more than six
months shall be reviewed by an LMHP, LMHP-R, LMHP-RP, or LMHP-S who shall
document the continued need for the service. The ISP shall be rewritten at
least annually.
3. The enrolled
provider of psychosocial rehabilitation services shall be licensed by DBHDS as
a provider of psychosocial rehabilitation services.
4. Psychosocial rehabilitation services may
be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or a
qualified paraprofessional under the supervision of a QMHP-A, QMHP-C, QMHP-E,
LMHP, LMHP-R, LMHP-RP, or LMHP-S.
5. The program shall operate a minimum of two
continuous hours in a 24-hour period.
6. Time allocated for field trips may be used
to calculate time and units if the goal is to provide training in an integrated
setting and to increase the individual's understanding or ability to access
community resources.
E.
Initiation of crisis intervention services shall be indicated following a
comprehensive needs assessment completed by an LMHP, LMHP-R, LMHP-RP, or LMHP-S
or a certified prescreener assessment that documents a marked reduction in the
individual's psychiatric, adaptive, or behavioral functioning or an extreme
increase in personal distress. In order to receive reimbursement, providers
shall register this service with DMAS or its contractor within one business day
of the completion of the comprehensive needs assessment to avoid duplication of
services and to ensure informed care coordination.
1. The crisis intervention services provider
shall be licensed as a provider of emergency services by DBHDS.
2. Client-related activities provided in
association with a face-to-face contact are reimbursable.
3. An ISP shall not be required for newly
admitted individuals to receive this service. Inclusion of crisis intervention
as a service on the ISP shall not be required for the service to be provided on
an emergency basis.
4. For
individuals receiving scheduled, short-term counseling as part of the crisis
intervention service, an ISP shall be developed or revised to reflect the
short-term counseling goals by the fourth face-to-face contact.
5. Reimbursement shall be provided for
short-term crisis counseling contacts occurring within a 30-day period from the
time of the first face-to-face crisis contact. There are no restrictions
(regarding number of contacts or a given time period to be covered) for
reimbursement for unscheduled crisis contacts.
6. Crisis intervention services may be
provided to eligible individuals outside of the clinic and reimbursed, provided
the provision of out-of-clinic services is clinically or programmatically
appropriate. Travel by staff to provide out-of-clinic services shall not be
reimbursable. Crisis intervention may involve contacts with the family or
significant others. If other clinic services are billed at the same time as
crisis intervention, documentation must clearly support the separation of the
services with distinct treatment goals.
7. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall
conduct a comprehensive needs assessment, or a certified prescreener shall
conduct a face-to-face comprehensive assessment that documents the need for and
the anticipated duration of the crisis service.
8. Crisis intervention shall be provided by
either an LMHP, LMHP-R, LMHP-RP, LMHP-S, or a certified prescreener.
9. For an admission to a freestanding
inpatient psychiatric facility for individuals younger than 21 years of age,
federal regulations (42 CFR
441.152) require certification of the
admission by an independent team. The independent team must include mental
health professionals, including a physician. These preadmission screenings
cannot be billed unless the requirement for an independent team certification,
with a physician's signature, is met.
10. Services shall be documented through
daily notes and a daily log of time spent in the delivery of
services.
F. Case
management services pursuant to
12VAC30-50-420 (Case management
services for seriously mentally ill adults and emotionally disturbed children)
or 12VAC30-50-430 (Case management
services for youth at risk of serious emotional disturbance).
1. Reimbursement shall be provided only for
"active" case management clients, as defined. An active client for case
management shall mean an individual for whom there is an ISP in effect that
requires regular direct or client-related contacts or activity or communication
with the individuals or families, significant others, service providers, and
others, including a minimum of one face-to-face individual contact within a
90-day period. Billing can be submitted only for months in which direct or
client-related contacts, activity, or communications occur.
2. The Medicaid-eligible individual shall
meet the DBHDS criteria of serious mental illness, serious emotional
disturbance in children and adolescents, or youth at risk of serious emotional
disturbance.
3. There shall be no
maximum service limits for case management services.
4. Reimbursement is allowed for case
management services for Medicaid-eligible individuals who are in institutions
pursuant to
12VAC30-50-420 and
12VAC30-50-430.
5. The ISP shall document the need for case
management and be fully completed within 30 calendar days of initiation of the
service. The case manager shall review the ISP at least every 90 calendar days.
Such reviews shall be documented in the individual's medical record.
6. Reviews will be due by the end of the
month following the 90th calendar day from when the last review was completed.
If needed, a grace period will be granted up to the last day of the next month.
If the review was completed in a grace period, the next subsequent review shall
be required within 90 calendar days from when the review was due and not the
date of the actual review.
7. The
ISP shall also be updated at least annually.
8. The provider of case management services
shall be licensed by DBHDS as a provider of case management services.
G. Intensive community treatment
(ICT).
1. A comprehensive needs assessment
that documents eligibility and the need for this service shall be completed by
either the LMHP, LMHP-R, LMHP-RP, or LMHP-S prior to the initiation of
services. The comprehensive needs assessment documentation shall be maintained
in the individual's records.
2. An
ISP, based on the needs as determined by the comprehensive needs assessment,
must be initiated at the time of admission and must be fully developed by
either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E and
approved by the LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 days of the
initiation of services.
3. ICT may
be billed if the individual is brought to the facility by ICT staff to see the
psychiatrist. Documentation must be present in the individual's record to
support this intervention.
4. The
enrolled ICT provider shall be licensed by DBHDS as a provider of intensive
community services or as a program of assertive community treatment and must
provide and make available emergency services 24 hours per day, seven days per
week, 365 days per year, either directly or on call.
5. ICT services must be documented through a
daily log of time spent in the delivery of services and a description of the
activities or services provided. There must also be at least a weekly note
documenting progress or lack of progress toward goals and objectives as
outlined on the ISP.
H.
Crisis stabilization services.
1. This service
shall be initiated following a face-to-face comprehensive needs assessment by
either an LMHP, LMHP-R, LMHP-RP, or LMHP-S or an assessment completed by a
certified prescreener that documents the need for crisis stabilization
services.
2. In order to receive
reimbursement, providers shall register this service with DMAS or its
contractor within one business day of the completion of the provider's
assessment to avoid duplication of services and to ensure informed care
coordination.
3. The ISP must be
developed or revised within three calendar days of admission to this service.
The LMHP, LMHP-R, LMHP-RP, LMHP-S, certified prescreener, QMHP-A, QMHP-C, or
QMHP-E shall develop the ISP.
4.
Room and board, custodial care, and general supervision are not components of
this service.
5. Clinic option
services are not billable at the same time crisis stabilization services are
provided, with the exception of clinic visits for medication management.
Medication management visits may be billed at the same time that crisis
stabilization services are provided, but documentation must clearly support the
separation of the services with distinct treatment goals.
6. Individuals qualifying for this service
must demonstrate a clinical necessity for the service arising from a condition
due to an acute crisis of a psychiatric nature which puts the individual at
risk of psychiatric hospitalization.
7. Providers of residential crisis
stabilization shall be licensed by DBHDS as providers of residential or
nonresidential crisis stabilization services. Providers of community-based
crisis stabilization shall be licensed by DBHDS as providers of mental health
nonresidential crisis stabilization.
I. Mental health skill-building services
(MHSS) as defined in
12VAC30-50-226 B
6.
1. At
admission, an appropriate face-to-face comprehensive needs assessment must be
conducted, documented, signed, and dated by the LMHP, LMHP-R, LMHP-RP, or
LMHP-S. Providers shall be reimbursed one unit for each intake utilizing the
appropriate billing code. Services of any individual that continue more than
six months shall be reviewed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S who shall
document the continued need for the service in the individual's medical
record.
2. The primary mental
health diagnosis shall be documented as part of the comprehensive needs
assessment by the LMHP, LMHP-R, LMHP-RP, or LMHP-S performing the comprehensive
needs assessment.
3. The LMHP,
LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E shall complete, sign, and
date the ISP within 30 days of the admission to this service. The ISP shall
include documentation of how many days per week and how many hours per week are
required to carry out the goals in the ISP. The total time billed for the week
shall not exceed the frequency established in the individual's ISP. The ISP
shall indicate the dated signature of the LMHP, LMHP-R, LMHP-RP, LMHP-S,
QMHP-A, QMHP-C, or QMHP-E and the individual. The ISP shall indicate the
specific training and services to be provided, the goals and objectives to be
accomplished, and criteria for discharge as part of a discharge plan that
includes the projected length of service. If the individual refuses to sign the
ISP, this shall be noted in the individual's medical record
documentation.
4. Every three
months, the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E shall
review with the individual in a manner in which the individual may participate
with the process, modify as appropriate, and update the ISP. The ISP must be
rewritten at least annually.
a. The goals,
objectives, and strategies of the ISP shall be updated to reflect any change in
the individual's progress and treatment needs as well as any newly identified
problem.
b. Documentation of this
review shall be added to the individual's medical record no later than 15
calendar days from the date of the review, as evidenced by the dated signatures
of the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E and the
individual.
5. The ISP
shall include discharge goals that will enable the individual to achieve and
maintain community stability and independence. The ISP shall fully support the
need for interventions over the length of the period of service requested from
the service authorization contractor.
6. Reauthorizations for service shall only be
granted if the provider demonstrates to either DMAS or the service
authorization contractor that the individual is benefitting from the service as
evidenced by updates and modifications to the ISP that demonstrate progress
toward ISP goals and objectives.
7.
If the provider knows or has reason to know of the individual's nonadherence to
a regimen of prescribed medication, medication adherence shall be a goal in the
individual's ISP. If the care is delivered by the qualified paraprofessional,
the supervising LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C shall be
informed of any nonadherence to the prescribed medication regimen. The LMHP,
LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C shall coordinate care with the
prescribing physician regarding any concerns about medication nonadherence,
provided that the individual has consented to such sharing of information. The
provider shall document the following minimum elements of the contact between
the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C and the prescribing
physician:
a. Name and title of
caller;
b. Name and title of
professional who was called;
c.
Name of organization for which the prescribing professional works;
d. Date and time of call;
e. Reason for the care coordination
call;
f. Description of the
medication regimen issue discussed; and
g. Whether there was a resolution of the
medication regimen issue.
8. Discharge summaries shall be prepared by a
provider for all of the individuals in the provider's care.
9. Documentation of prior psychiatric
services history shall be maintained in the individual's mental health
skill-building services medical record. The provider shall document evidence of
the individual's prior psychiatric services history, as required by
12VAC30-50-226 B 6 b
(3) and
12VAC30-50-226 B 6 c
(4), by contacting the prior provider of such
health care services after obtaining written consent from the individual.
Documentation of telephone contacts with the prior provider shall include the
following minimum elements:
a. Name and title
of caller;
b. Name and title of
professional who was called;
c.
Name of organization for which the professional works;
d. Date and time of call;
e. Specific placement provided;
f. Type of treatment previously
provided;
g. Name of treatment
provider; and
h. Dates of previous
treatment.
Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
10. The provider shall document evidence of
the psychiatric medication history, as required by
12VAC30-50-226 B 6 b
(4) and
12VAC30-50-226 B 6 c
(5), by maintaining a photocopy of
prescription information from a prescription bottle or by contacting the
current or previous prescribing provider of health care services or pharmacy
after obtaining written consent from the individual. Prescription lists or
medical records, including discharge summaries, obtained from the pharmacy or
current or previous prescribing provider of health care services that contain
(i) the name of the prescribing physician, (ii) the name of the medication with
dosage and frequency, and (iii) the date of the prescription shall be
sufficient to meet these criteria. Family member statements shall not suffice
to meet this requirement.
11. In
the absence of such documentation, the current provider shall document all
contacts (i.e., telephone, faxes, electronic communication) with the pharmacy
or provider of health care services with the following minimum elements:
(i) name and title of caller,
(ii) name and title of prior professional who
was called,
(iii) name of
organization for whom the professional works,
(iv) date and time of call,
(v) specific prescription confirmed,
(vi) name of prescribing physician,
(vii) name of medication, and
(viii) date of
prescription.
12. Only
direct face-to-face contacts and services to an individual shall be
reimbursable.
13. Any services
provided to the individual that are strictly academic in nature shall not be
billable. These include such basic educational programs as instruction or
tutoring in reading, science, mathematics, or GED.
14. Any services provided to individuals that
are strictly vocational in nature shall not be billable. However, support
activities and activities directly related to assisting an individual to cope
with a mental illness to the degree necessary to develop appropriate behaviors
for operating in an overall work environment shall be billable.
15. Room and board, custodial care, and
general supervision are not components of this service.
16. Provider qualifications. The enrolled
provider of mental health skill-building services must be licensed by DBHDS as
a provider of mental health community support as defined in
12VAC35-105-20. Individuals
employed or contracted by the provider to provide mental health skill-building
services must have training in the characteristics of mental illness and
appropriate interventions, training strategies, and support methods for persons
with mental illness and functional limitations. Mental health skill-building
services shall be provided by either an LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A,
QMHP-C, QMHP-E, or QPPMH. The LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C
will supervise the care weekly if delivered by the QMHP-E or QPPMH.
Documentation of supervision shall be maintained in the mental health
skill-building services record.
17.
Mental health skill-building services shall be documented through a daily log
of time involved in the delivery of services and a minimum of a weekly summary
note of services provided. The provider shall clearly document services
provided to detail what occurred during the entire amount of the time
billed.
18. If mental health
skill-building services are provided in a therapeutic group home or assisted
living facility, effective July 1, 2014, there shall be a yearly limit of up to
416 units per fiscal year and a weekly limit of up to eight units per week,
with at least half of each week's services provided outside of the group home
or assisted living facility. There shall be a daily limit of a maximum of two
units. Prior to July 1, 2014, the previous limits shall apply. DMAS or its
contractor may authorize additional units of mental health skill-building
services that exceed this limit based on documented medical necessity. The ISP
shall not include activities that contradict or duplicate those in the
treatment plan established by the group home or assisted living facility. The
provider shall attempt to coordinate mental health skill-building services with
the treatment plan established by the group home or assisted living facility
and shall document all coordination activities in the medical record.
19. Limits and exclusions.
a. Therapeutic group home and assisted living
facility providers shall not serve as the mental health skill-building services
provider for individuals residing in the provider's respective facility.
Individuals residing in facilities may, however, receive MHSS from another MHSS
agency not affiliated with the owner of the facility in which they
reside.
b. Mental health
skill-building services shall not be reimbursed for individuals who are
receiving in-home residential services or congregate residential services
through the Intellectual Disability Waiver or Individual and Family
Developmental Disabilities Support Waiver.
c. Mental health skill-building services
shall not be reimbursed for individuals who are also receiving independent
living skills services, the Department of Social Services independent living
program (22VAC40-151), independent living services (22VAC40-131 and
22VAC40-151), or independent living arrangement (22VAC40-131) or any
Comprehensive Services Act-funded independent living skills programs.
d. Mental health skill-building services
shall not be available to individuals who are receiving treatment foster care
(12VAC30-130-900 et
seq.).
e. Mental health
skill-building services shall not be available to individuals who reside in
intermediate care facilities for individuals with intellectual disabilities or
hospitals.
f. Mental health
skill-building services shall not be available to individuals who reside in
nursing facilities, except for up to 60 days prior to discharge. If the
individual has not been discharged from the nursing facility during the 60-day
period of services, mental health skill-building services shall be terminated
and no further service authorizations shall be available to the individual
unless a provider can demonstrate and document that mental health
skill-building services are necessary. Such documentation shall include facts
demonstrating a change in the individual's circumstances and a new plan for
discharge requiring up to 60 days of mental health skill-building
services.
g. Mental health
skill-building services shall not be available for residents of psychiatric
residential treatment centers, except for the assessment code H0032 (modifier
U8) in the seven days immediately prior to discharge.
h. Mental health skill-building services
shall not be reimbursed if personal care services or attendant care services
are being received simultaneously, unless justification is provided regarding
why this is necessary in the individual's mental health skill-building services
record. Medical record documentation shall fully substantiate the need for
services when personal care or attendant care services are being provided. This
applies to individuals who are receiving additional services through the
Developmental Disability Waivers (12VAC30-122), the Commonwealth Coordinated
Care Plus Waiver (12VAC30-120-900 et seq.), and
EPSDT services (12VAC30-50-130).
i. Mental health skill-building services
shall not be duplicative of other services. Providers have a responsibility to
ensure that if an individual is receiving additional therapeutic services that
there will be coordination of services by either the LMHP, LMHP-R, LMHP-RP,
LMHP-S, QMHP-A, QMHP-C, or QMHP-E to avoid duplication of services.
j. Individuals who have organic disorders,
such as delirium, dementia, or other cognitive disorders not elsewhere
classified, will be prohibited from receiving mental health skill-building
services unless the individual's physician issues a signed and dated statement
indicating that the individual could benefit from this service.
k. Individuals who are not diagnosed with a
serious mental health disorder but who have personality disorders or other
mental health disorders, or both, that may lead to chronic disability, will not
be excluded from the mental health skill-building services eligibility
criteria, provided that the individual has a primary mental health diagnosis
from the list included in
12VAC30-50-226 B 6 b
(1) or
12VAC30-50-226 B 6 c
(2) and that the provider can document and
describe how the individual is expected to actively participate in and benefit
from mental health support services.
J. Except as noted in subdivision I 18 of
this section and in
12VAC30-50-226 B 6
e, the limits described in this section and
in 12VAC30-50-226 shall apply to all
service authorization requests submitted to either DMAS or the behavioral
health services agency as of July 27, 2016. As of July 27, 2016, all annual
limits, weekly limits, daily limits, and reimbursement for services shall apply
to all services described in
12VAC30-50-226 regardless of the
date upon which service authorization was obtained.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia.
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