There are a couple of rules open for public comment until November 13, 2016.
Several manuals will change in this rule change proposal. Here are the important changes:
All of these documents can be found in full here.
Please send your comments to robert.nix@dhs.arkansas.gov.
LMHP-2-16 Provider Manual Update
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
INPPSYCH-3-16 Provider Manual Update
| 203.100 Facility-Based Community Reintegration Program | 7-1-17 |
The Facility-Based Community Reintegration Program is designed to serve as an intermediate level of care between inpatient psychiatric facilities and outpatient services. To enroll as a freestanding Facility-Based Community Reintegration Program unit or as a Facility-Based Community Reintegration Program unit within an inpatient psychiatric hospital, the inpatient psychiatric provider must meet all of the conditions listed below:
- The provider must meet the child and adolescent standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and be accredited by JCAHO.
- Any provider located within Arkansas must be licensed by the Arkansas Department of Human Services as a Facility-Based Community Reintegration Program.
This manual, the Inpatient Psychiatric Services for Under Age 21 Provider Manual, shall govern all aspects of services provided as well as claim submissions for beneficiaries of the Facility-Based Community Reintegration Program.
| 211.000 Scope | 7-1-17 |
G. Under the direction of a physician (contracted physicians are acceptable).
A standardized independent assessment will determine eligibility for Inpatient Psychiatric Services for Persons Under Age 21. The standardized independent assessment must be performed by an independent entity.
The independent assessment will contain additional criteria and questions, which will be asked based upon results from the independent assessment to determine eligibility for Inpatient Psychiatric Services for Persons Under Age 21. Acute inpatient psychiatric care will not require an independent assessment.
The standardized independent assessment must be conducted at least every 12 months by an independent assessor in consultation with the beneficiary and anyone the beneficiary requests to participate in the standardized independent assessment. The standardized independent assessment will also take into consideration information obtained from behavioral health service providers that are providing services to the beneficiary.
A beneficiary must be referred to the independent assessment entity to evaluate whether the beneficiary meets the eligibility criteria for Inpatient Psychiatric Services for Persons Under Age 21. The following are allowable methods of referral to receive a standardized independent assessment for determination of eligibility for Inpatient Psychiatric Services for Persons Under Age 21:
A. Trigger from claims data/MMIS claims data
B. Referral from counseling level services provider
C. Referral from physician (including those in acute settings, mobile crisis units)
D. An individual determined to be medically fragile due to behavior health needs
E. Referral from the Division of Children and Family Services (DCFS)/the Division of Youth Services (DYS) when they are the legal guardian of the beneficiary
F. Referral/court order from the court system/justice system
G. Referral from care coordination entity
A re-assessment can be requested by the direct behavioral health service provider or the care coordination entity if the direct behavioral health service provider or care coordination entity determines the beneficiary’s needs are not being met or the beneficiary is not benefitting from the Inpatient Psychiatric Services for Persons Under Age 21 being provided.
The independent assessor will contact the beneficiary to be assessed within 48 hours of referral and will complete the face-to-face assessment within 14 calendar days. For identified priority populations, the independent assessor will contact the beneficiary to be assessed within 24 hours of notification from the beneficiary’s provider and will complete the assessment within 7 days of the notification. Examples of priority population include, but are not to be limited to:
A. Youth involved in the juvenile justice system
B. Individuals involved in the foster care system
C. Individuals discharged from acute hospital stays
D. Individuals discharged from crisis residential stays
E. Adults involved in the criminal justice system
F. Clients identified and referred by the Division of Behavioral Health Services (DBHS)
| 250.500 Facility-Based Community Reintegration Program | 7-1-17 |
The per diem rates for Facility-Based Community Reintegration Programs are established at the lesser of: 1) the center’s budgeted cost per day which includes the professional component or 2) a $245 per day upper limit (cap). This is a prospective rate with no cost settlement.
The budgeted per diem cost is calculated from the annual budget, which all Facility-Based Community Reintegration Program providers are required to submit for the upcoming state fiscal year (July 1st through June 30th). Annual budgets are due by April 30th. Should April 30th fall on a Saturday, Sunday or state or federal holiday, the due date shall be the following business day. Failure to submit the budget by April 30th may result in the suspension of reimbursement until the budget is submitted. Rates are calculated annually and are effective for dates of service occurring during the state fiscal year for which the budgets have been prepared.
New providers are required to submit a full year’s annual budget for the current state fiscal year (July 1st through June 30th) at the time of enrollment. This budget is used to set their rate at the lesser of the budgeted allowable cost per day or the upper limit (cap) of $245 per day.
RSPMI-4-16 Provider Manual Update
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
SATS-2-16 Provider Manual Update
The transition process to eliminate the Rehabilitative Services for Persons with Mental Illness (RSPMI) Program, Licensed Mental Health Practitioner (LMHP) Program and the Substance Abuse Treatment Services (SATS) Program is contingent upon the approval of the implementation of the Outpatient Behavioral Health Services Program. Clients currently served by the RSPMI, LMHP and SATS programs will begin transitioning to the Outpatient Behavioral Health Program starting July 1, 2017. RSPMI, LMHP and SATS will cease to exist on June 30, 2018 and no Arkansas Medicaid payments will occur to any RSPMI, LMHP or SATS provider for services provided after June 30, 2018.
SBMH-1-16 Provider Manual Update
* There are several smaller changes in this manual that deserve notice, but here’s the biggest.
| 211.300 Primary Care Physician (PCP) Referral | 7-1-17 |
Each beneficiary who receives School-Based Mental Health Services can receive a limited amount of services. Once those limits are reached, a Primary Care Physician (PCP) referral or Patient-Centered Medical Home (PCMH) approval will be necessary to continue treatment. This referral or approval must be retained in the beneficiary’s medical record.
A beneficiary can receive three (3) School-Based Mental Health Services before a PCP/PCMH referral is necessary. No services will be allowed to be provided without appropriate PCP/PCMH referral. The PCP/PCMH referral must be kept in the beneficiary’s medical record.
The Patient-Centered Medical Home (PCMH) will be responsible for coordinating care with a beneficiary’s PCP or physician for School-Based Mental Health Services. Medical responsibility for beneficiaries receiving School-Based Mental Health Services shall be vested in a physician licensed in Arkansas.
The PCP referral or PCMH authorization for School-Based Mental Health Services will serve as the prescription for those services.
See Section I of this manual for the PCP procedures. A PCP referral is generally obtained prior to providing service to Medicaid-eligible children. However, a PCP is given the option of providing a referral after a service is provided. If a PCP chooses to make a referral after a service has been provided, the referral must be received by the SBMH provider no later than 45 calendar days after the date of service. The PCP has no obligation to give a retroactive referral.
| 214.000 Covered Services | 7-1-17 |
Outpatient Services
Fifteen-minute units, unless otherwise stated.
Outpatient Behavioral Health Services must be billed on a per-unit basis, as reflected in a daily total, per beneficiary, per service.
| One (1) unit = | 8–24 minutes |
| Two (2) units = | 25–39 minutes |
| Three (3) units = | 40–49 minutes |
| Four (4) units = | 50–60 minutes |
Time spent providing services for a single beneficiary may be accumulated during a single, 24-hour calendar day. Providers may accumulatively bill for a single date of service, per beneficiary, per Outpatient Behavioral Health service. Providers are not allowed to accumulatively bill for spanning dates of service.
All billing must reflect a daily total, per Outpatient Behavioral Health service, based on the established procedure codes. No rounding is allowed.
The sum of the days’ time, in minutes, per service will determine how many units are allowed to be billed. That number must not be exceeded. The total number of minutes per service must be compared to the following grid, which determines the number of units allowed.
| One (1) unit = | 8–24 minutes |
| Two (2) units = | 25–39 minutes |
| Three (3) units = | 40–49 minutes |
| Four (4) units = | 50–60 minutes |
In a single-claim transaction, a provider may bill only for service time accumulated within a single day for a single beneficiary. There is no “carryover” of time from one day to another or from one beneficiary to another.
Documentation in the beneficiary’s record must reflect exactly how the number of units is determined.
No more than four (4) units may be billed for a single hour per beneficiary or provider of the service.
| 219.100 Record Reviews | 7-1-17 |
The Division of Medical Services (DMS) of the Arkansas Department of Human Services (DHS) has contracted with an independent contractor to perform on-site inspections of care (IOC) and retrospective reviews of outpatient mental health services provided by Outpatient Behavioral Health Services providers. View or print current contractor contact information. The reviews are conducted by licensed mental health professionals and are based on applicable federal and state laws, rules and professionally recognized standards of care.
| 228.130 Retrospective Reviews | 7-1-17 |
The Division of Medical Services (DMS) of the Arkansas Department of Human Services has contracted with a Quality Improvement Organization (QIO) or QIO-like organization to perform retrospective (post-payment) reviews of outpatient mental health services provided by Outpatient Behavioral Health providers. View or print current contractor contact information.
The reviews will be conducted by licensed mental health professionals who will examine the medical record for compliance with federal and state laws and regulations.
| 228.131 Purpose of a Review | 7-1-17 |
The purpose of a review is to:
- Ensure that services are delivered in accordance with the treatment plan and conform to generally accepted professional standards.
- Evaluate the medical necessity of services provided to Medicaid beneficiaries.
- Evaluate the clinical documentation to determine if it is sufficient to support the services billed during the requested period of authorized services.
- Safeguard the Arkansas Medicaid program against unnecessary or inappropriate use of services and excess payments in compliance with 42 CFR § 456.3(a).
| 229.000 Medicaid Beneficiary Appeal Process | 7-1-17 |
If an adverse decision is received, the beneficiary may request a fair hearing of the denial decision.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services within thirty days of the date on the letter explaining the denial of services.
| 229.200 Recoupment Process | 7-1-17 |
The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate the recoupment process for all claims that the current contractor has denied because the records submitted do not support the claim of medical necessity.
Arkansas Medicaid will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid beneficiary name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.
| 272.110 Mental Health Diagnosis | 7-1-17 |
| CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
| 90791 | Psychiatric diagnostic evaluation (with no medical services) | |
| SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
| Mental Health Diagnosis is a clinical service for the purpose of determining the existence, type, nature and appropriate treatment of a mental illness or related disorder as described in the current allowable DSM. This service may include time spent for obtaining necessary information for diagnostic purposes. The psychodiagnostic process may include, but is not limited to, a psychosocial and medical history, diagnostic findings, and recommendations. This service must include a face-to-face component and will serve as the basis for documentation of modality and issues to be addressed (Plan of Care). Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. | · Date of service· Start and stop times of the face-to-face encounter with the beneficiary and the interpretation time for diagnostic formulation· Place of service· Identifying information· Referral reason· Presenting problem(s), history of presenting problem(s) including duration, intensity and response(s) to prior treatment· Culturally- and age-appropriate psychosocial history and assessment· Mental status/clinical observations and impressions· Current functioning plus strengths and needs in specified life domains· DSM diagnostic impressions to include all axes· Treatment recommendations· Goals and objectives to be placed in Plan of Care· Staff signature/credentials/date of signature | |
| NOTES | UNIT | BENEFIT LIMITS |
| This service may be billed for face-to-face contact as well as for time spent obtaining necessary information for diagnostic purposes; however, this time may NOT be used for development or submission of required paperwork processes (i.e. treatment plans, etc.). | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
| APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
| Children and Youth | Outpatient Behavioral Health Services Providers cannot bill 90791 on same date of service | |
| ALLOWED MODE(S) OF DELIVERY | TIER | |
| Face-to-face | School-Based Mental Health | |
| ALLOWABLE PERFORMING PROVIDER | PLACE OF SERVICE | |
| · Licensed Certified Social Worker (LCSW)· Licensed Master Social Worker (LMSW)· Licensed Professional Counselor (LPC)· Licensed Associate Counselor (LAC)· Licensed Psychological Examiner (LPE)· Psychologist* School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
| 272.120 Psychological Evaluation | 7-1-17 |
| CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
| 96101 | Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, Rorschach®, WAIS®), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. | |
| SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
| Psychological evaluation for personality assessment includes psychodiagnostic assessment of a beneficiary’s emotional, personality, and psychopathology, e.g. MMPI, Rorschach®, and WAIS®. Psychological testing is billed per hour both face-time administering tests and time interpreting these tests and preparing the report. This service may reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the beneficiary. Medical necessity for this service is met when:• the service is necessary to establish a differential diagnosis of behavioral or psychiatric conditions;• history and symptomatology are not readily attributable to a particular psychiatric diagnosis; or• questions to be answered by the evaluation could not be resolved by a psychiatric/diagnostic interview, observation in therapy or an assessment for level of care at a mental health facility. | • Date of service• Start and stop times of actual encounter with beneficiary• Start and stop times of scoring, interpretation and report preparation• Place of service• Identifying information• Rationale for referral• Presenting problem(s)• Culturally- and age-appropriate psychosocial history and assessment• Mental status/clinical observations and impressions• Psychological tests used, results, and interpretations, as indicated• DSM diagnostic impressions to include all axes• Treatment recommendations and findings related to rationale for service and guided by test results• Staff signature/credentials/date of signature(s) | |
| NOTES | UNIT | BENEFIT LIMITS |
| 60 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 8 | |
| APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
| Children and Youth | ||
| ALLOWED MODE(S) OF DELIVERY | TIER | |
| Face-to-face | School-Based Mental Health | |
| ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
| • Licensed Psychological Examiner (LPE)• Psychologist | 03 | |
| 272.130 Interpretation of Diagnosis | 7-1-17 |
| CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
| 90887 | Interpretation or explanation of results of psychiatric or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient | |
| SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
| Interpretation of Diagnosis is a direct service provided for the purpose of interpreting the results of psychiatric or other medical exams, procedures or accumulated data. Services may include diagnostic activities and/or advising the beneficiary and his/ her family. Consent forms may be required for family or significant other involvement. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. | • Start and stop times of face to face encounter with beneficiary and/or parents or guardian• Date of service• Place of service• Participants present and relationship to beneficiary• Diagnosis• Rationale for and objective used that must coincide with the goals and objectives placed in Plan of Care• Participant(s) response and feedback• Staff signature/credentials/date of signature(s) | |
| NOTES | UNIT | BENEFIT LIMITS |
| For beneficiaries under the age of 18, the time may be spent face-to-face with the beneficiary, the beneficiary and the parent(s) or guardian(s) or alone with the parent(s) or guardian(s). For beneficiaries over the age of 18, the time may be spent face-to-face with the beneficiary and the spouse, legal guardian or significant other. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 1 |
| APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
| Children and Youth | ||
| ALLOWED MODE(S) OF DELIVERY | TIER | |
| Face-to-face | School-Based Mental Health | |
| ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
| • Licensed Certified Social Worker (LCSW)• Licensed Master Social Worker (LMSW)• Licensed Professional Counselor (LPC)• Licensed Associate Counselor (LAC)• Licensed Psychological Examiner (LPE)• Psychologist* School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
| 272.140 Marital/Family Behavioral Health Counseling with Beneficiary Present | 7-1-17 |
| CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
| 90847 | Family psychotherapy with patient present (conjoint psychotherapy) | |
| SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
| Marital/Family Behavioral Health Counseling with Beneficiary Present is a face-to-face treatment provided to one or more family members in the presence of a beneficiary. Services must be congruent with the age and abilities of the beneficiary, client-centered and strength-based, with emphasis on needs as identified by the beneficiary and provided with cultural competence. Services are designed to enhance insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services pertain to a beneficiary’s (a) Mental Health and/or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. | • Date of Service• Start and stop times of actual encounter with beneficiary and spouse/family• Place of service• Participants present and relationship to beneficiary• Diagnosis and pertinent interval history• Brief mental status of beneficiary and observations of beneficiary with spouse/family • Rationale for, and description of treatment used, that must coincide with the master treatment plan and improve the impact the beneficiary’s condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the spouse/family.• Beneficiary and spouse/family’s response to treatment that includes current progress or regression and prognosis• Any changes indicated for the master treatment plan, diagnosis, or medication(s)• Plan for next session, including any homework assignments and/or crisis plans• Staff signature/credentials/date of signature• HIPAA compliant release of Information, completed, signed and dated | |
| NOTES | UNIT | BENEFIT LIMITS |
| Natural supports may be included in these sessions if justified in service documentation. Only one beneficiary per family per therapy session may be billed. | Encounter | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 12 |
| APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
| Children and Youth | ||
| ALLOWED MODE(S) OF DELIVERY | TIER | |
| Face-to-face | School-Based Mental Health | |
| ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
| • Licensed Certified Social Worker (LCSW)• Licensed Master Social Worker (LMSW)• Licensed Professional Counselor (LPC)• Licensed Associate Counselor (LAC)• Licensed Psychological Examiner (LPE)• Psychologist* School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
| 272.150 Crisis Intervention | 7-1-17 |
| CPT®/HCPCS PROCEDURE CODE | PROCEDURE CODE DESCRIPTION | |
| H2011, HA | Crisis intervention service, per 15 minutes | |
| SERVICE DESCRIPTION | MINIMUM DOCUMENTATION REQUIREMENTS | |
| Crisis Intervention is unscheduled, immediate, short-term treatment activities provided to a Medicaid-eligible beneficiary who is experiencing a psychiatric or behavioral crisis. Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family. These services are designed to stabilize the person in crisis, prevent further deterioration and provide immediate indicated treatment in the least restrictive setting. (These activities include evaluating a Medicaid-eligible beneficiary to determine if the need for crisis services is present.) | • Date of service• Start and stop time of actual encounter with beneficiary and possible collateral contacts with caregivers or informed persons• Place of service• Specific persons providing pertinent information in relationship to beneficiary• Diagnosis and synopsis of events leading up to crisis situation• Brief mental status and observations• Utilization of previously established psychiatric advance directive or crisis plan as pertinent to current situation OR rationale for crisis intervention activities utilized• Beneficiary’s response to the intervention that includes current progress or regression and prognosis• Clear resolution of the current crisis and/or plans for further services• Development of a clearly defined crisis plan or revision to existing plan• Staff signature/credentials/date of signature(s) | |
| NOTES | UNIT | BENEFIT LIMITS |
| A psychiatric or behavioral crisis is defined as an acute situation in which an individual is experiencing a serious mental illness or emotional disturbance to the point that the beneficiary or others are at risk for imminent harm or in which to prevent significant deterioration of the beneficiary’s functioning.This service can be provided to beneficiaries that have not been previously assessed or have not previously received behavioral health services.The provider of this service MUST complete a Mental Health Diagnosis (90791) within 7 days of provision of this service. If the beneficiary needs more time to be stabilized, this must be noted in the beneficiary’s medical record and the Division of Medical Services Quality Improvement Organization (QIO) must be notified. | 15 minutes | DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12 YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 72 |
| APPLICABLE POPULATIONS | SPECIAL BILLING INSTRUCTIONS | |
| Children and Youth | ||
| ALLOWED MODE(S) OF DELIVERY | TIER | |
| Face-to-face | School-Based Mental Health | |
| ALLOWABLE PERFORMING PROVIDERS | PLACE OF SERVICE | |
| • Licensed Certified Social Worker (LCSW)• Licensed Master Social Worker (LMSW)• Licensed Professional Counselor (LPC)• Licensed Associate Counselor (LAC)• Licensed Psychological Examiner (LPE)• Psychologist* School-Based Mental Health Services provider employees or contractors will provide services only in those areas in which they are licensed or credentialed. | 03 | |
Medicaid Saves Lives 