016.19.18 Ark. Code R. § 003 - Outpatient Behavioral Health Services Progra Provider Manual 3-18 and Certifiction Manual

Section II Outpatient Behavioral Health Services
200.000 OUTPATIENT BEHAVIORAL HEALTH SERVICES GENERAL INFORMATION
201.000 Introduction 1-1-19

Medicaid (Medical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Outpatient Behavioral Health Services are covered by Medicaid when provided to eligible Medicaid beneficiaries by enrolled providers.

Outpatient Behavioral Health Services may be provided to eligible Medicaid beneficiaries at all provider certified/enrolled sites. Allowable places of service are found in the service definitions located in Section 252and Section 255 of this manual.

202.000 Arkansas Medicaid Participation Requirements for Outpatient 1-1-19

Behavioral Health Services

All behavioral health providers approved to receive Medicaid reimbursement for services to Medicaid beneficiaries must meet specific qualifications for their services and staff. Providers with multiple service sites must enroll each site separately and reflect the actual service site on billing claims.

Behavioral Health Providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:

A. Providers must be located within the State of Arkansas.
B. A provider must be certified by the Division of Provider Services and Quality Assurance (DPSQA). (See Section 202.100 for specific certification requirements.)
C. A copy of the current DPSQA certification as a Behavioral Health provider must accompany the provider application and Medicaid contract.
D. The provider must give notification to the Office of the Medicaid Inspector General (OMIG) on or before the tenth day of each month of all covered health care practitioners who perform services on behalf of the provider. The notification must include the following information for each covered health care practitioner:
1. Name/Title
2. Enrolled site(s) where services are performed
3. Social Security Number
4. Date of Birth
5. Home Address
6. Start Date
7. End Date (if applicable)

Notification is not required when the list of covered health care practitioners remains unchanged from the previous notification.

DMS shall exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(a) and implementing regulations and may exclude providers for the reasons stated in 42 U.S.C. § 1320a-7(b) and implementing regulations. The following factors shall be considered by DHS in determining whether sanction(s) should be imposed:

A. Seriousness of the offense(s)
B. Extent of violation(s)
C. History of prior violation(s)
D. Whether an indictment or information was filed against the provider or a related party as defined in DHS Policy 1088, titled DHS Participant Exclusion Rule.
202.100 Certification Requirements by the Division of Provider Services and 1-1-19

Quality Assurance (DPSQA)

In order to enroll into the Outpatient Behavioral Health Services Medicaid program as a Performing Provider or Group for Counseling Services or a Behavioral Health Agency, all performing providers, provider groups, and business entities participating in the Medicaid Outpatient Behavioral Health Services (OBH) Program must be certified by the Division of Provider Services and Quality Assurance. The DPSQA Certification Rules for Providers of Outpatient Behavioral Health Services is located at http://humanservices.arkansas.gov/dbhs/Pages/dbhs_docs.aspx.

Behavioral Health Agencies must have national accreditation that recognizes and includes all of the applicant's programs, services and service sites. Any outpatient behavioral health program service site associated with a hospital must have a free-standing behavioral health outpatient program national accreditation. Providers must meet all other DPSQA certification requirements in addition to accreditation.

210.000 PROGRAM COVERAGE
211.000 Coverage of Services 1-1-19

Outpatient Behavioral Health Services are limited to certified providers who offer core behavioral health services for the treatment of behavioral disorders. All performing providers, provider groups, and business entities participating in the Medicaid Outpatient Behavioral Health Services (OBH) Program must be certified by the Division Provider Services and Quality Assurance.

An Outpatient Behavioral Health Services provider must establish a site specific emergency response plan that complies with the DPSQA Certification Rules for Providers of Outpatient Behavioral Health Services. Each agency site must have 24-hour emergency response capability to meet the emergency treatment needs of the Behavioral Health Services beneficiaries served by the site. The provider must implement and maintain a written policy reflecting the specific coverage plan to meet this requirement. A machine recorded voice mail message to call 911 or report to the nearest emergency room in and of itself is not sufficient to meet the requirement.

Licensed performing providers as certified by DPSQA must also maintain an Emergency Service Plan that complies with the DPSQA Certification Rules for Providers of Outpatient Behavioral Health Services manual.

All Outpatient Behavioral Health Services providers must demonstrate the capacity to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.

211.100 Quality Assurance 1-1-19

Each Behavioral Health Agency must establish and maintain a quality assurance committee that will meet quarterly and examine the clinical records for completeness, adequacy and appropriateness of care, quality of care and efficient utilization of provider resources. The committee must also comply with the DPSQA Certification Rules for Providers of Outpatient Behavioral Health Services manual. Documentation of quality assurance committee meetings and quality improvement programs must be filed separately from the clinical records.

211.200 Staff Requirements 1-1-19

Each Outpatient Behavioral Health Services provider must ensure that they employ staff which is able and available to provide appropriate and adequate services offered by the provider. Behavioral Health staff members must provide services only within the scope of their individual licensure. The following chart lists the terminology used in this provider manual and explains the licensure, certification and supervision that are required for each performing provider type.

PROVIDER TYPE

LICENSES

STATE CERTIFICATION REQUIRED

SUPERVISION

Independently Licensed Clinicians - Master's/Doctoral

Licensed Clinical Social Worker (LCSW)

Licensed Marital and Family Therapist (LMFT)

Licensed Psychologist (LP)

Licensed Psychological Examiner - Independent (LPEI)

Licensed Professional Counselor (LPC)

Yes, must be certified to provide services

Not Required

Independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

Licensed Clinical Social Worker (LCSW)

Licensed Marital and Family Therapist (LMFT)

Licensed Psychologist (LP)

Licensed Psychological Examiner - Independent (LPEI)

Licensed Professional Counselor (LPC)

Yes, must be certified to provide services

Not Required

Non-independently Licensed Clinicians - Master's/Doctoral

Licensed Master Social Worker (LMSW)

Licensed Associate Marital and Family Therapist (LAMFT)

Licensed Associate Counselor (LAC)

Licensed Psychological Examiner (LPE)

Provisionally Licensed Psychologist (PLP)

Yes, must be supervised by appropriate Independently Licensed Clinician

Required

Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

Licensed Master Social Worker (LMSW)

Licensed Associate Counselor (LAC)

Licensed Psychological Examiner (LPE)

Provisionally Licensed Psychologist (PLP)

Yes, must be supervised by appropriate Independently Licensed Clinician and must be certified to provide services

Required

Advanced Practice Nurse (APN)

Adult Psychiatric Mental Health Clinical Nurse Specialist

Child Psychiatric Mental Health Clinical Nurse Specialist

Adult Psychiatric Mental Health APN

Family Psychiatric Mental Health APN

No, must be part of a certified agency or have a Collaborative Agreement with a Physician

Collaborative Agreement with Physician Required

Physician

Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

No, must provide proof of licensure

Not Required

The services of a medical records librarian are required. The medical records librarian (or person performing the duties of the medical records librarian) shall be responsible for ongoing quality controls, for continuity of patient care and patient traffic flow. The librarian shall assure that records are maintained, completed and preserved; that required indexes and registries are maintained and that statistical reports are prepared. This staff member will be personally responsible for ensuring that information on enrolled patients is immediately retrievable, establishing a central records index, and maintaining service records in such a manner as to enable a constant monitoring of continuity of care.

When an Outpatient Behavioral Health Services provider files a claim with Arkansas Medicaid, the staff member who actually performed the service must be identified on the claim as the rendering provider. This action is taken in compliance with the federal Improper Payments Information Act of 2002 (IPIA), Public Law 107-300 and the resulting Payment Error Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).

211.300 Certification of Performing Providers 1-1-19

As illustrated in the chart in § 211.200, certain Outpatient Behavioral Health performing providers are required to be certified by the Division Provider Services and Quality Assurance. The certification requirements for performing providers are located on the DPSQA website at http://humanservices.arkansas.gov/dbhs/Pages/dbhs_docs.aspx.

211.500 Non-Refusal Requirement 1-1-19

The Outpatient Behavioral Health Services provider may not refuse services to a Medicaid-eligible beneficiary who meets the requirements for Outpatient Behavioral Health Services as outlined in this manual. If a provider does not possess the services or program to adequately treat the beneficiary's behavioral health needs, the provider must communicate this with the Primary Care Physician (PCP) or Patient-Centered Medical Home (PCMH) for beneficiaries receiving Counseling Services so that appropriate provisions can be made.

212.000 Scope 1-1-19

The Outpatient Behavioral Health Services Program provides care, treatment and services which are provided by a certified Behavioral Health Services provider to Medicaid-eligible beneficiaries that have a Behavioral Health diagnosis as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-5 and subsequent revisions).

Eligibility for services depends on the needs of the beneficiary. Counseling Level Services and Crisis Services can be provided to any beneficiary as long as the services are medically necessary

COUNSELING LEVEL SERVICES

Time-limited behavioral health services provided by qualified licensed practitioners in an outpatient-based setting for the purpose of assessing and treating mental health and/or substance abuse conditions. Counseling Services settings shall mean a behavioral health clinic/office, healthcare center, physician office, child advocacy center, home, shelter, group home, and/or school.

213.000 Outpatient Behavioral Health Services Program Entry 1-1-19

Prior to continuing provision of Counseling Level Services, the provider must document medical necessity of Outpatient Behavioral Health Counseling Services. The documentation of medical necessity is a written intake assessment that evaluates the beneficiary's mental condition and,

based on the beneficiary's diagnosis, determines whether treatment in the Outpatient Behavioral Health Services Program is appropriate. This documentation must be made part of the beneficiary's medical record.

The intake assessment , either the Mental Health Diagnosis (CPT Code 90791), Substance Abuse Assessment (CPT Code H0001), or Psychiatric Assessment (CPT Code 90792), must be completed prior to the provision of Counseling Level Services in the Outpatient Behavioral Health Services program. This intake will assist providers in determining services needed and desired outcomes for the beneficiary. The intake must be completed by a mental health professional qualified by licensure and experienced in the diagnosis and treatment of behavioral health and/or substance use disorders.

213.100 Independent Assessment Referral 1-1-19

Please refer to the Independent Assessment Manual or the PASSE Manual for Independent Assessment Referral Process.

214.000 Role of Providers of Counseling Level Services 1-1-19

Outpatient Behavioral Health Providers provide Counseling Level Services by qualified licensed practitioners in an outpatient based setting for the purpose of assessing and treating behavioral health conditions. Counseling Level Services outpatient based setting shall mean services rendered in a behavioral health clinic/ office, healthcare center, physician office, home, shelter, group home, and/or school. The performing provider must provide services only within the scope of their individual licensure. Services available to be provided by Counseling Level Services providers are listed in Section 252.111 through 255.001 of the Outpatient Behavioral Health Services manual.

214.100 Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 1-1-19

months & Parent/Caregiver)

Outpatient Behavioral Health Providers may provide dyadic treatment of beneficiary's age 0-47 months and the parent/caregiver of the eligible beneficiary. A prior authorization will be required for all dyadic treatment services (the Mental Health Diagnosis and Interpretation of Diagnosis DO NOT require a prior authorization). All performing providers of parent/caregiver and child Outpatient Behavioral Health Services MUST be certified by DAABHS to provide those services.

Providers will diagnose children through the age of 47 months based on the DC: 0-3R. Providers will then crosswalk the DC: 0-3R diagnosis to a DMS diagnosis. Specified V codes will be allowable for this population.

217.100 Primary Care Physician (PCP) Referral 1-1-19

Each beneficiary that receives only Counseling Level Services in the Outpatient Behavioral Health Services program can receive a limited amount of Counseling Level Services. Once those limits are reached, a Primary Care Physician (PCP) referral or 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) Counseling Level services before a PCP/PCMH referral is necessary. Crisis Intervention (Section 255.001) does not count toward the three (3) counseling level services. No services, except Crisis Intervention, will be allowed to be provided without appropriate PCP/PCMH referral. The PCP/PCMH 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 Counseling Level Services. Medical responsibility for beneficiaries receiving Counseling Level Services shall be vested in a physician licensed in Arkansas.

The PCP referral or PCMH authorization for Counseling Level Services will serve as the prescription for those services.

Verbal referrals from PCPs or PCMHs are acceptable to Medicaid as long as they are documented in the beneficiary's chart as described in Section 171.410.

See Section I of this manual for an explanation of the process to obtain a PCP referral.

219.200 Telemedicine (Interactive Electronic Transactions) Services 1-1-19

See Section I for Telemedicine policy and Section III for Telemedicine billing protocol.

220.000 Inpatient Hospital Services 1-1-19

Regulation for Inpatient Hospital Services may be found in program specific manuals located at:

https://medicaid.mmis.arkansas.gov/Provider/Docs/Docs.aspx

223.000 Exclusions 1-1-19

Services not covered under the Outpatient Behavioral Health Program include, but are not limited to:

A. Room and board residential costs
B. Educational services
C. Telephone contacts with patient
D. Transportation services, including time spent transporting a beneficiary for services

(reimbursement for other Outpatient Behavioral Health services is not allowed for the period of time the Medicaid beneficiary is in transport)

E. Services to individuals with developmental disabilities that are non-psychiatric in nature
F. Services which are found not to be medically necessary
G. Services provided to nursing home and ICF/IDD residents other than those specified in the applicable populations sections of the service definitions in this manual
224.000 Physician's Role 1-1-19

Certified Counseling Level Services providers must have relationships with a physician licensed in Arkansas in order to ensure psychiatric and medical conditions are monitored and addressed by appropriate physician oversight.

Medical supervision responsibility shall include, but is not limited to, the following:

A. A beneficiary can receive three (3) Counseling Level Services before a PCP/PCMH referral is necessary in the medical record (see Section 217.100). Medical responsibility will be vested in a physician licensed in Arkansas who signs the PCP referral or PCMH approval for Counseling Level Services of the Outpatient Behavioral Health Services program.
227.000 Prescription for Outpatient Behavioral Health Services 1-1-19

Each beneficiary that receives only Counseling Level Services can receive a limited amount of Counseling Level Services without a Primary Care Physician (PCP) referral or Patient-Centered Medical Home (PCMH) approval. Once those limits are reached, a PCP referral or PCMH approval will be necessary. This approval by the PCP or PCMH will serve as the prescription for Counseling Level Services in the Outpatient Behavioral Health Services program. Please see Section 217.100 for limits. Medicaid will not cover any service outside of the established limits without a current prescription signed by the PCP or PCMH.

Prescriptions shall be based on consideration of an evaluation of the enrolled beneficiary. The prescription of the services and subsequent renewals must be documented in the beneficiary's medical record.

228.114 Cases Chosen for Review 1-1-19

The contractor will review twenty (20) randomly selected cases during the IOC review. If a provider has fewer than 20 open cases, all cases shall be reviewed.

The review period shall be specified in the provider notification letter. The list of cases to be reviewed shall be given to the provider upon arrival or chosen by the IOC Team from a list for the provider site. The components of the records required for review include:

A. All required assessments
B. Progress notes, including physician notes
C. Physician orders and lab results
D. Copies of records. The reviewer shall retain a copy of any record reviewed.
228.120 DMS/DBHS Work Group Reports and Recommendations 1-1-19

The DMS/DAABHS Work Group (comprised of representatives from the Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General, the Division of Aging Adult and Behavioral Health Services (DAABHS), the Division of Provider Services and Quality Assurance, the utilization review agency, as well as other units or divisions as required) will meet monthly to discuss IOC reports.

If a deficiency related to safety or potential risk to the beneficiary or others is found, then the utilization review agency shall immediately report this to the DMS Director (or the Director's designee).

228.121 Corrective Action Plans 1-1-19

The provider must submit a Corrective Action Plan designed to correct any deficiency noted in the written report of the IOC. The provider must submit the Corrective Action Plan to the contracted utilization review agency within 30 calendar days of the date of the written report. The contractor shall review the Corrective Action Plan and forward it, with recommendations, to the DMS Behavioral Health Unit, the Arkansas Office of Medicaid Inspector General and Division of Provider Services and Quality Assurance (DPSQA).

After acceptance of the Corrective Action Plan, the utilization review agency will monitor the implementation and effectiveness of the Corrective Action Plan via on-site review. DMS, its contractor(s) or both may conduct a desk review of beneficiary records. The desk review will be site-specific and not by organization. If it is determined that the provider has failed to meet the conditions of participation, DMS will determine if sanctions are warranted.

228.122 Actions 1-1-19

Actions that may be taken following an inspection of care review include, but are not limited to:

A. Decertification of any beneficiary determined as not meeting medical necessity criteria for outpatient mental health services
B. Decertification of any provider determined to be noncompliant with the Division of Provider Services and Quality Assurance (DPSQA) provider certification rules
C. On-site monitoring by the utilization review agency to verify the implementation and effectiveness of corrective actions
D. The contractor may recommend, and DMS may require, follow-up inspections of care and/or desk reviews. Follow-up inspections may review the issues addressed by the Corrective Action Plans or may be a complete re-inspection of care, at the sole discretion of the Division of Medical Services
E. Review and revision of the Corrective Action Plan
F. Review by the Arkansas Office of Medicaid Inspector General
G. Formulation of an emergency transition plan for beneficiaries including those in custody of DCFS and DYS
H. Suspension of provider referrals
I. Placement in high priority monitoring
J. Mandatory monthly staff training by the utilization review agency
K. Provider requirement for one of the following staff members to attend a DMS/DAABHS monthly work group meeting: Clinical Director/Designee (at least a master's level mental health professional) or Executive Officer
L. Recoupment for services that are not medically necessary or that fail to meet professionally recognized standards for health care
M. Any sanction identified in Section 152.000
228.132 Review Sample and the Record Request 1-1-19

On a calendar quarterly basis, the contractor will select a statistically valid random sample from an electronic data set of all Outpatient Behavioral Health beneficiaries whose dates of service occurred during the three-month selection period. If a beneficiary was selected in any of the three calendar quarters prior to the current selection period, then they will be excluded from the sample and an alternate beneficiary will be substituted. The utilization review process will be conducted in accordance with 42 CFR § 456.23.

A written request for medical record copies will be mailed to each provider who provided services to the beneficiaries selected for the random sample along with instructions for submitting the medical record. The request will include the beneficiary's name, date of birth, Medicaid identification number and dates of service. The request will also include a list of the medical record components that must be submitted for review. The time limit for a provider to request reconsideration of an adverse action/decision stated in § 1 of the Medicaid Manual shall be the time limit to furnish requested records. If the requested information is not received by the deadline, a medical necessity denial will be issued.

All medical records must be submitted to the contractor via fax, mail or electronic medium. View or print current contractor contact information. ." Records will not be accepted via email.

228.133 Review Process 1-1-19

The record will be reviewed using a review tool based upon the promulgated Medicaid Outpatient Behavioral Health Services manual. The review tool is designed to facilitate review of regulatory compliance, incomplete documentation and medical necessity. All reviewers must have a professional license in therapy (LCSW, LMSW, LPE, LPE-I, LPC, LAC, LMFT, LAMFT, etc.). The reviewer will screen the record to determine whether complete information was submitted for review. If it is determined that all requested information was submitted, then the reviewer will review the documentation in more detail to determine whether it meets medical necessity criteria based upon the reviewer's professional judgment.

If a reviewer cannot determine that the services were medically necessary, then the record will be given to a psychiatrist for review. If the psychiatrist denies some or all of the services, then a denial letter will be sent to the provider and the beneficiary. Each denial letter contains a rationale for the denial that is record specific and each party is provided information about requesting reconsideration review or a fair hearing.

The reviewer will also compare the paid claims data to the progress notes submitted for review. When documentation submitted does not support the billed services, the reviewer will deny the services which are not supported by documentation. If the reviewer sees a deficiency during a retrospective review, then the provider will be informed that it has the opportunity to submit information that supports the paid claim. If the information submitted does not support the paid claim, the reviewer will send a denial letter to the provider and the beneficiary. Each denial letter contains a rationale for the denial that is record-specific and each party is provided information about requesting reconsideration review or a fair hearing.

Each retrospective review, and any adverse action resulting from a retrospective review, shall comply with the Medicaid Fairness Act. DMS will ensure that its contractor(s) is/are furnished a copy of the Act.

231.100 Prior Authorization 1-1-19

Prior Authorization is required for certain Outpatient Behavioral Health Services provided to Medicaid-eligible beneficiaries.

Prior Authorization requests must be sent to the DMS contracted entity to perform prior authorizations for beneficiaries under the age of 21 and for beneficiaries age 21 and over for services that require a Prior Authorization. View or print current contractor contact information. Information related to clinical management guidelines and authorization request processes is available at current contractor's website.

Procedure codes requiring prior authorization:

National Codes

Required Modifier

Service Title

90832

UC, UK, U4

Individual Behavioral Health Counseling - Age 3

90834

UC, UK U4

Individual Behavioral Health Counseling - Age 3

90837

UC, UK, U4

Individual Behavioral Health Counseling - Age 3

90847

UC, UK, U4

Marital/Family Behavioral Health Counseling with Beneficiary Present - Dyadic Treatment

H2027

UK, U4

Psychoeducation - Dyadic Treatment

231.300 Substance Abuse Covered Codes

Certain Outpatient Behavioral Health Services are covered by Arkansas Medicaid for an individual whose primary diagnosis is substance abuse. Independently Licensed Practitioners may provide Substance Abuse Service within the scope of their practice. Behavioral Health Agency sites must be licensed by the Divisions of Provider Services and Quality Assurance in order to provide Substance Abuse Services. Allowable substance abuse services are listed below:

National Codes

Required Modifier

Service Title

90832

U4 U5

Individual Behavioral Health Counseling - Substance Abuse

90834

U4 U5

Individual Behavioral Health Counseling - Substance Abuse

90837

U4 U5

Individual Behavioral Health Counseling - Substance Abuse

90853

U4 U5

Group Behavioral Health Counseling - Substance Abuse

90846

U4 U5

Marital/Family Behavioral Health Counseling - without Beneficiary Present - Substance Abuse

90847

U4 U5

Marital/Family Behavioral Health Counseling with Beneficiary Present - Substance Abuse

90849

U4 U5

Multi-Family Behavioral Health Counseling - Substance Abuse

90791

Mental Health Diagnosis

90887

Interpretation of Diagnosis

H0001

U4

Substance Abuse Assessment

Beneficiaries being treated by an Outpatient Behavioral Health Service provider for a mental health disorder who also have a co-occurring substance use disorder(s), this (these) substance use disorder(s) is (are) listed as a secondary diagnosis. Outpatient Behavioral Health Service Agency providers that are certified to provide Substance Abuse services may also provider substance abuse treatment to their behavioral health clients. In the provision of Outpatient Behavioral Health mental health services, the substance use disorder is appropriately focused on with the client in terms of its impact on and relationship to the primary mental health disorder.

A Behavioral Health Agency and Independently Licensed Practitioner may provide substance abuse treatment services to beneficiaries who they are also providing mental health/behavioral health services to. In this situation, the substance abuse disorder must be listed as the secondary diagnosis on the claim with the mental health/behavioral health diagnosis as the primary diagnosis.

240.100 Reimbursement 1-1-19

Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure.

Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying that the beneficiary is eligible for Arkansas Medicaid prior to rendering services.

A. Outpatient Services

Fifteen-Minute Units, unless otherwise stated

Outpatient Behavioral Health Services must be billed on a per unit basis as indicated in the service definition, as reflected in a daily total, per beneficiary, per service.

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 of minutes per service must be compared to the following grid, which determines the number of units allowed.

15 Minute Units

Timeframe

One (1) unit =

8-24 minutes

Two (2) units =

25 -39 minutes

Three (3) units =

40 - 49 minutes

Four (4) units =

50 - 60 minutes

60 minute Units

Timeframe

One (1) unit =

50-60 minutes

Two (2) units =

110-120 minutes

Three (3) units =

170-180 minutes

Four (4) units =

230-240 minutes

Five (5) units =

290-300 minutes

Six (6) units =

350-360 minutes

Seven (7) units=

410-420 minutes

Eight (8) units=

470-480 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.

B. Inpatient Services

The length of time and number of units that may be billed for inpatient hospital visits are determined by the description of the service in Current Procedural Terminology (CPT).

241.000 Fee Schedule 1-1-19

Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://medicaid.mmis.arkansas.gov/Provider/Docs/fees.aspx under the provider manual section. The fees represent the fee-for-service reimbursement methodology.

Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.

Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.

252.100 Procedure Codes for Types of Covered Services 1-1-19

Covered Behavioral Health Services are outpatient services. Specific Behavioral Health Services are available to inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine, and to nursing home residents. Outpatient Behavioral Health Services are billed on a per unit or per encounter basis as listed. All services must be provided by at least the minimum staff within the licensed or certified scope of practice to provide the service.

Benefits are separated by Level of Service. A beneficiary can receive three (3) Counseling Level Services before a PCP/PCMH referral is necessary in the medical record.

The allowable services differ by the age of the beneficiary and are addressed in the Applicable Populations section of the service definitions in this manual.

252.111 Individual Behavioral Health Counseling 1-1-19

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90832, U4

90832: psychotherapy, 30 min

90834, U4

90834: psychotherapy, 45 min

90837, U4

90832, U4, GT - Telemedicine 90834, U4, GT - Telemedicine 90837, U4, GT - Telemedicine 90832, U4, U5 - Substance Abuse 90834, U4, U5 - Substance Abuse 90837, U4, U5 - Substance Abuse 90832, UC, UK, U4 - Under Age 4 90834, UC, UK, U4 - Under Age 4 90837, UC, UK, U4 - Under Age 4

90837: psychotherapy, 60 min

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Individual Behavioral Health Counseling is a face-to-face treatment provided to an individual in an outpatient setting for the purpose of treatment and remediation of a condition as described in the current allowable DSM. The treatment service must reduce or alleviate identified symptoms related to either (a) Mental Health or (b) Substance Abuse, and maintain or improve level of functioning, and/or prevent deterioration. Additionally, tobacco cessation counseling is a component of this service.

* Date of Service

* Start and stop times of face-to-face encounter with beneficiary

* Place of service

* Diagnosis and pertinent interval history

* Brief mental status and observations

* Rationale and description of the treatment used that must coincide with Mental Health Diagnosis

* Beneficiary's response to treatment that includes current progress or regression and prognosis

* Any revisions indicated for the diagnosis, or medication concerns

* Plan for next individual therapy session, including any homework assignments and/or advanced psychiatric directive or crisis plans

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

Services provided must be congruent with the objectives and interventions articulated on the most recent Mental Health Diagnosis. Services must be consistent with established behavioral healthcare standards. Individual Psychotherapy is not permitted with beneficiaries who do not have the cognitive ability to benefit from the service.

This service is not for beneficiaries under the age of 4 except in documented exceptional cases. This service will require a Prior Authorization for beneficiaries under the age of 4.

90832: 30 minutes 90834: 45 minutes 90837: 60 minutes

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED:

90832: 1

90834: 1

90837: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested):

Counseling Level Beneficiary: 12

encounters between all 3 codes

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults Residents of Long Term Care Facilities

A provider may only bill one Individual Behavioral Health Counseling Code per day per beneficiary. A provider cannot bill any other Individual Behavioral Health Counseling Code on the same date of service for the same beneficiary. For Counseling Level Beneficiaries, there are 12 total individual counseling encounters allowed per year regardless of code billed for Individual Behavioral Health Counseling unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid.

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Telemedicine (Adults, Youth, and Children)

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE (POS)

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

* Providers of services for beneficiaries under age 4 must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.112 Group Behavioral Health Counseling

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90853, U4

90853, U4, U5 - Substance Abuse

Group psychotherapy (other than of a multiple-family group)

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Group Behavioral Health Counseling is a face-to-face treatment provided to a group of

* Date of Service

beneficiaries. Services leverage the emotional interactions of the group's members to assist in each beneficiary's treatment process, support his/her rehabilitation effort, and to minimize relapse.. 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.

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 actual group encounter that includes identified beneficiary

* Place of service

* Number of participants

* Diagnosis

* Focus of group

* Brief mental status and observations

* Rationale for group counseling must coincide with Mental Health Assessment

* Beneficiary's response to the group counseling that includes current progress or regression and prognosis

* Any changes indicated for diagnosis, or medication concerns

* Plan for next group session, including any homework assignments and/ or crisis plans

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

This does NOT include psychosocial groups. Beneficiaries eligible for Group Behavioral Health Counseling must demonstrate the ability to benefit from experiences shared by others, the ability to participate in a group dynamic process while respecting the others' rights to confidentiality, and must be able to integrate feedback received from other group members. For groups of beneficiaries aged 18 and over, the minimum number that must be served in a specified group is 2. The maximum that may be served in a specified group is 12. For groups of beneficiaries under 18 years of age, the minimum number that must be served in a specified group is 2. The maximum that may be served in a specified group is 10. A beneficiary must be 4 years of age to receive group therapy. Group treatment must be age and developmentally appropriate, (i.e., 16 year olds and 4 year olds must not be treated in the same group). Providers may bill for services only at times during which beneficiaries participate in group activities.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested):

Counseling Level Beneficiary: 12 encounters

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

A provider can only bill one Group Behavioral Health Counseling encounter per day. For Counseling Level Beneficiaries, there are 12 total group behavioral health counseling encounters allowed per year unless an extension of benefits is allowed by the Quality Improvement Organization contracted with Arkansas Medicaid.

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

03 (School), 11 (Office), 49 (Independent Clinic), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substances Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.113 Marital/Family Behavioral Health Counseling with Beneficiary

Present

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90847, U4

90847, U4, U5 - Substance Abuse

90847, UC, UK, U4 - Dyadic Treatment *

Family psychotherapy (conjoint psychotherapy) (with patient present)

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 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.

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.

*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. Dyadic treatment must be prior authorized and is only available for beneficiaries in Tier 1. Dyadic Infant/Caregiver Psychotherapy is a behaviorally based therapy that involves improving the parent-child relationship by transforming the interaction between the two parties.

* 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 Mental Health Diagnosis 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 diagnosis, or medication concerns

* Plan for next session, including any homework assignments and/or crisis plans

* Staff signature/credentials/date of signature

* HIPAA compliant Release of Information,

The primary goal of Dyadic Infant/Parent Psychotherapy is to strengthen the relationship between a child and his or her parent (or caregiver) as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect and improving the child's cognitive, behavioral, and social functioning. This service uses child directed interaction to promote interaction between the parent and the child in a playful manner. Providers must utilize a national recognized evidence based practice. Practices include, but are not limited to, Child-Parent Psychotherapy (CPP) and Parent Child Interaction Therapy (PCIT).

completed, signed and dated

NOTES

UNIT

BENEFIT LIMITS

Natural supports may be included in these sessions if justified in service documentation and if supported in the documentation in the Mental Health Diagnosis. Only one beneficiary per family per therapy session may be billed.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested):

Counseling Level Beneficiaries: 12 encounters

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

A provider can only bill one Marital / Family Behavioral Health Counseling with (or without) Patient encounter per day. There are 12 total Marital/Family Behavioral Health Counseling with Beneficiary Present encounters allowed per year unless an extension of benefits is allow by the Quality Improvement Organization contracted with Arkansas Medicaid.

The following codes cannot be billed on the Same Date of Service:

90849 - Multi-Family Behavioral Health Counseling

90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present

H2027 - Psychoeducation

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians -Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

* Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.114 Marital/Family Behavioral Health Counseling without Beneficiary

Present

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90846, U4

90846, U4, U5 - Substance Abuse

SERVICE DESCRIPTION

Marital/Family Behavioral Health Counseling without Beneficiary Present is a face-to-face treatment provided to one or more family members outside the presence of a beneficiary. 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.

Services must be congruent with the age and abilities of the beneficiary or family member(s), client-centered and strength-based; with emphasis on needs as identified by the beneficiary and family and provided with cultural

Family psychotherapy (without the patient present)

MINIMUM DOCUMENTATION REQUIREMENTS

* Date of Service

* Start and stop times of actual encounter spouse/family

* Place of service

* Participants present and relationship to beneficiary

* Diagnosis and pertinent interval history

* Brief observations with spouse/family

* Rationale for, and description of treatment used that must coincide with the Mental Health Diagnosis and improve the impact the beneficiary's condition has on the spouse/family and/or improve marital/family interactions between the beneficiary and the

competence.

spouse/family.

* Beneficiary and spouse/family's response to treatment that includes current progress or regression and prognosis

* Any changes indicated for the diagnosis, or medication concerns

* 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 and if supported in Mental Health Diagnosis. Only one beneficiary per family per therapy session may be billed.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested):

Counseling Level Beneficiaries: 12 encounters

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

A provider can only bill one Marital / Family Behavioral Health Counseling with (or without) Beneficiary encounter per day.

The following codes cannot be billed on the Same Date of Service:

90849 - Multi-Family Behavioral Health Counseling

90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present

H2027 - Psychoeducation

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians -Master's/Doctoral

03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

(Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.115 Psychoeducation

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

H2027, U4

H2027, U4, GT - Telemedicine

H2027, UK, U4 - Dyadic Treatment*

Psychoeducational service; per 15 minutes

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Psychoeducation provides beneficiaries and their families with pertinent information regarding mental illness, substance abuse, and tobacco cessation, and teaches problem-solving, communication, and coping skills to support recovery. Psychoeducation can be implemented in two formats: multifamily group and/or single family group. Due to the group format, beneficiaries and their families are also able to benefit from support of peers and mutual aid. 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.

*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. Dyadic treatment must be prior authorized. Providers must utilize a national recognized evidence based practice. Practices include, but are not limited to, Nurturing Parents and Incredible Years.

* Date of Service

* Start and stop times of actual encounter with beneficiary and spouse/family

* Place of service

* Participants present

* Nature of relationship with beneficiary

* Rationale for excluding the identified beneficiary

* Diagnosis and pertinent interval history

* Rationale for and objective used that must coincide with Mental Health Diagnosis 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.

* Spouse/Family response to treatment that includes current progress or regression and prognosis

* Any changes indicated diagnosis, or medication concerns

* Plan for next session, including any homework assignments and/or crisis plans

* HIPAA compliant Release of Information forms, completed, signed and dated

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

Information to support the appropriateness of excluding the identified beneficiary must be documented in the service note and medical record. Natural supports may be included in

15 minutes

DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4

these sessions when the nature of the relationship with the beneficiary and that support's expected role in attaining treatment goals is documented. Only one beneficiary per family per therapy session may be billed.

YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 48

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

A provider can only bill a total of 48 units of Psychoeducation

The following codes cannot be billed on the Same Date of Service:

90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present

90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present

90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Telemedicine (Adults, Youth, and Children)

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians -Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

* Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians -Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90849, U4

90849, U4, U5 - Substance Abuse

Multiple-family group psychotherapy

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Multi-Family Behavioral Health Counseling is a group therapeutic intervention using face-to-face verbal interaction between two (2) to a maximum of nine (9) beneficiaries and their family members or significant others. Services are a more cost-effective alternative to Marital/Family Behavioral Health Counseling, designed to enhance members' insight into family interactions, facilitate inter-family emotional or practical support and to develop alternative strategies to address familial issues, problems and needs. Services may pertain to a beneficiary's (a) Mental Health or (b) Substance Abuse condition. Additionally, tobacco cessation counseling is a component of this service. 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 family and provided with cultural competence.

* Date of Service

* Start and stop times of actual encounter with beneficiary and/or spouse/family

* Place of service

* Participants present

* Nature of relationship with beneficiary

* Rationale for excluding the identified beneficiary

* Diagnosis and pertinent interval history

* Rationale for and objective used to 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.

* Spouse/Family 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

* HIPAA compliant Release of Information forms, completed, signed and dated

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

May be provided independently if patient is being treated for substance abuse diagnosis only. Comorbid substance abuse should be provided as integrated treatment utilizing Family Psychotherapy.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): 12

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

There are 12 total Multi-Family Behavioral Health Counseling encounters allowed per year.

The following codes cannot be billed on the

Same Date of Service:

90846 - Marital/Family Behavioral Health Counseling without Beneficiary Present

90847 - Marital/Family Behavioral Health Counseling with Beneficiary Present

90887 - Interpretation of Diagnosis

90887 - Interpretation of Diagnosis, Telemedicine

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians -Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

03 (School), 11 (Office), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.117 Mental Health Diagnosis

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90791, U4

90791, U4, GT - Telemedicine

90791, UC, UK, U4 - Dyadic Treatment *

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

* Treatment recommendations, and prognosis for treatment

* 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

This service can be provided via telemedicine to beneficiaries only ages 21 and above.

*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months & parent/caregiver. A Mental Health Diagnosis will be required for all children through 47 months to receive services. This service includes up to four encounters for children through the age of 47 months and can be provided without a prior authorization. This service must include an assessment of:

o Presenting symptoms and behaviors;

o Developmental and medical history;

o Family psychosocial and medical history;

o Family functioning, cultural and communication patterns, and current environmental conditions and stressors;

o Clinical interview with the primary caregiver and observation of the caregiver-infant relationship and interactive patterns;

o Child'saffective,language, cognitive, motor, sensory, self-care, and social functioning.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): 1

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults Residents of Long Term Care

The following codes cannot be billed on the Same Date of Service:

90792 - Psychiatric Assessment

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face Telemedicine (Adults Only)

Counseling

ALLOWABLE PERFORMING PROVIDER

PLACE OF SERVICE

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

* Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 32 (Nursing Facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.118 Interpretation of Diagnosis

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90887, U4

90887, U4, GT - Telemedicine

90887, UC, UK, U4 - Dyadic Treatment

Interpretation or explanation of results of psychiatric, 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. Services pertain to a beneficiary's (a) Mental Health and/or (b) Substance Abuse condition 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 Mental Health Diagnosis

* Participant(s) response and feedback

* Recommendation for additional supports including referrals, resources and information

* 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.

This service can be provided via telemedicine to beneficiaries ages 18 and above. This service can also be provided via telemedicine to beneficiaries ages 17 and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record.

*Dyadic treatment is available for parent/caregiver & child for dyadic treatment of children age 0 through 47 months& parent/caregiver. Interpretation of Diagnosis will be required for all children through 47 months to receive services. This service includes up to four encounters for children through the age of 47 months and can be provided without a prior authorization. The Interpretation of Diagnosis is a direct service that includes an interpretation from a broader perspective the history and information collected through the Mental Health Diagnosis. This interpretation identifies and prioritizes the infant's needs, establishes a diagnosis, and helps to determine the care and services to be provided.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested):

Counseling Level Beneficiary: 1

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

The following codes cannot be billed on the Same Date of Service:

H2027 - Psychoeducation

90792 - Psychiatric Assessment

90849 - Multi-Family Behavioral Health Counseling

H0001 - Substance Abuse Assessment

This service can be provided via telemedicine to beneficiaries ages 18 and above. This service

can also be provided via telemedicine to beneficiaries ages 17 and under with documentation of parental or guardian involvement during the service. This documentation must be included in the medical record.

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Telemedicine Adults, Youth and Children

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

* Physician

* Providers of dyadic services must be trained and certified in specific evidence based practices to be reimbursed for those services o Independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider o Non-independently Licensed Clinicians - Parent/Caregiver & Child (Dyadic treatment of Children age 0-47 months & Parent/Caregiver) Provider

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.119 Substance Abuse Assessment

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

H0001, U4

Alcohol and/or drug assessment

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Substance Abuse Assessment is a service that identifies and evaluates the nature and extent of a beneficiary's substance abuse condition using the Addiction Severity Index (ASI) or an assessment instrument approved by DAABHS and DMS. The assessment must screen for and identify any existing co-morbid conditions. The assessment should assign a diagnostic impression to the beneficiary, resulting in a treatment recommendation and referral appropriate to effectively treat the condition(s) identified.

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 and strengths in specified life domains

* DSM diagnostic impressions

* Treatment recommendations and prognosis for treatment

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

The assessment process results in the assignment of a diagnostic impression, beneficiary recommendation for treatment regimen appropriate to the condition and situation presented by the beneficiary, initial plan (provisional) of care and referral to a service appropriate to effectively treat the condition(s) identified. If indicated, the assessment process must refer the beneficiary for a psychiatric consultation

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): 1

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

The following codes cannot be billed on the Same Date of Service:

90887 - Interpretation of Diagnosis

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral

* Advanced Practice Nurse

03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

* Physician

252.120 Psychological Evaluation 1-1-19

CPT®/HCPCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION

96101, U4 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 * Date of Service assessment includes psychodiagnostic

* Start and stop times of actual encounter with assessment of a beneficiary's emotional,

beneficiary personality, and psychopathology, e.g., MMPI,

Rorschach®, and WAIS®. Psychological testing * Start and stop times of scoring, interpretation is billed per hour both face-time administering and report preparation tests and time interpreting these tests and

* Place of service preparing the report. This service may reflect the mental abilities, aptitudes, interests,

* Identifying information attitudes, motivation, emotional and personality characteristics of the beneficiary. * Rationale for referral

Services must be congruent with the age and * Presenting problem(s)

abilities of the beneficiary, client-centered and

* Culturally and age-appropriate psychosocial strength-based; with emphasis on needs as history and assessment identified by the beneficiary and provided with cultural competence * Mental status/Clinical observations and impressions

* Psychological tests used, results, and Medical necessity for this service is met when:

interpretations, as indicated

* the service is necessary to establish a

* DSM diagnostic differential diagnosis of behavioral or psychiatric conditions * Treatment recommendations and findings related to rationale for service and guided by

* history and symptomatology are not readily test results attributable to a particular psychiatric diagnosis * Staff signature/credentials/date of signature(s)

* questions to be answered by the evaluation could not be resolved by a Mental Health Diagnosis or Psychiatric Assessment, observation in therapy, or an assessment for level of care at a mental health facility

* the service provides information relevant to the beneficiary's continuation in treatment and assists in the treatment process

NOTES

UNIT BENEFIT LIMITS

This code may not be billed for the completion of testing that is considered primarily educational or utilized for employment, disability qualification, or legal or court related purposes.

60 minutes

DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4

YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED (extension of benefits can be requested): 8

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Licensed Psychologist (LP)

* Licensed Psychological Examiner (LPE)

* Licensed Psychological Examiner - Independent (LPEI)

03 (School), 11 (Office), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 ( Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.121 Pharmacologic Management

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

99212, UB, U4 - Physician

99213, UB, U4 - Physician

99214, UB, U4 - Physician

99212, UB, U4, GT - Physician, Telemedicine

99213, UB, U4, GT - Physician, Telemedicine

99214, UB, U4, GT - Physician, Telemedicine

99212, SA, U4 - APN

99213, SA, U4 - APN

99214, SA, U4 - APN

99212, SA, U4, GT- APN, Telemedicine

99213, SA, U4, GT - APN, Telemedicine

99214, SA, U4, GT - APN, Telemedicine

99212: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making

99213: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.

99214: Office or other outpatient encounter for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history, A detailed examination; Medical decision making of moderate

complexity

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Pharmacologic Management is a service tailored to reduce, stabilize or eliminate psychiatric symptoms with the goal of improving functioning, including management and reduction of symptoms. This service includes evaluation of the medication prescription, administration, monitoring, and supervision and informing beneficiaries regarding medication(s) and its potential effects and side effects in order to make informed decisions regarding the prescribed medications. Services must be congruent with the age, strengths, and accommodations necessary for disability and cultural framework.

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 actual encounter with beneficiary

* Place of service (When 99 is used for telemedicine, specific locations of the beneficiary and the physician must be included)

* Diagnosis and pertinent interval history

* Brief mental status and observations

* Rationale for and treatment used that must coincide with the Psychiatric Assessment

* Beneficiary's response to treatment that includes current progress or regression and prognosis

* Revisions indicated for the diagnosis, or medication(s)

* Plan for follow-up services, including any crisis plans

* If provided by physician that is not a psychiatrist, then any off label uses of medications should include documented consult with the overseeing psychiatrist within 24 hours of the prescription being written

* Staff signature/credentials/date of signature

NOTES

UNIT

BENEFIT LIMITS

Applies only to medications prescribed to address targeted symptoms as identified in the Psychiatric Assessment.

Encounter

DAILY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): 12

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Telemedicine (Adults, Youth, and Children)

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Advanced Practice Nurse

* Physician

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office), 12 (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

252.122 Psychiatric Assessment

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

90792, U4

90792, U4, GT - Telemedicine

Psychiatric diagnostic evaluation with medical services

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Psychiatric Assessment is a face-to-face psychodiagnostic assessment conducted by a licensed physician or Advanced Practice Nurse (APN), preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under age 18). This service is provided to determine the existence, type, nature, and most appropriate treatment of a behavioral health disorder. This service is not required for beneficiaries to receive Counseling Level Services.

* 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

* The interview should obtain or verify all of the following:

1. The beneficiary's understanding of the factors leading to the referral

2. The presenting problem (including symptoms and functional impairments)

3. Relevant life circumstances and psychological factors

4. History of problems

5. Treatment history

6. Response to prior treatment interventions

7. Medical history (and examination as indicated)

* For beneficiaries under the age of 18

1. an interview of a parent (preferably both), the guardian (including the responsible DCFS caseworker) and/or the primary caretaker (including foster parents) in order to:

a) Clarify the reason for the referral b) Clarify the nature of the current symptoms c) Obtain a detailed medical, family and developmental history

* .Culturally and age-appropriate psychosocial history and assessment

* Mental status/Clinical observations and impressions

* Current functioning and strengths in specified life domains

* DSM diagnostic impressions

* Treatment recommendations

* 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 ENCOUNTERS THAT MAY BE BILLED: 1

YEARLY MAXIMUM OF ENCOUNTERS THAT MAY BE BILLED (extension of benefits can be requested): 1

APPLICABLE POPULATIONS

SPECIAL BILLING INSTRUCTIONS

Children, Youth, and Adults Telemedicine (Adults, Youth, and Children)

The following codes cannot be billed on the Same Date of Service:

90791 - Mental Health Diagnosis

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Counseling

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

A. an Arkansas-licensed physician, preferably one with specialized training and experience in psychiatry (child and adolescent psychiatry for beneficiaries under age 18)

B. an Adult Psychiatric Mental Health Advanced Nurse Practitioner/Family Psychiatric Mental Health Advanced Nurse Practitioner (PMHNP-BC)

The PMHNP-BC must meet all of the following requirements:

A. Licensed by the Arkansas State Board of Nursing

02 (Telemedicine), 03 (School), 04 (Homeless Shelter), 11 (Office), 12, (Patient's Home), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57 (Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic)

B. Practicing with licensure through the American Nurses Credentialing Center

C. Practicing under the supervision of an Arkansas-licensed psychiatrist with whom the PMHNP-BC has a collaborative agreement. The findings of the Psychiatric Assessment conducted by the PMHNP-BC must be discussed with the supervising psychiatrist within 45 days of the beneficiary entering care. The collaborative agreement must comply with all Board of Nursing requirements and must spell out, in detail, what the nurse is authorized to do and what age group they may treat.

D. Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act

E. Practicing within a PMHNP-BC's experience and competency level

255.001 Crisis Intervention

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

H2011, HA, U4

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.)

Services are to be congruent with the age, strengths, needed accommodation for any disability, and cultural framework of the beneficiary and his/her family.

* 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 provided to a beneficiary who is not currently a client. If the beneficiary cannot be contacted or does not return for a Mental Health Diagnosis appointment, attempts to contact the beneficiary must be placed in the beneficiary's medical record. 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, Youth, and Adults

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

Crisis

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

* Independently Licensed Clinicians - Master's/Doctoral

* Non-independently Licensed Clinicians - Master's/Doctoral (must be employed by Behavioral Health Agency)

* Advanced Practice Nurse

* Physician (must be employed by Behavioral Health Agency)

03 (School), 04 (Homeless Shelter), 11 (Office) 12 (Patient's Home), 15 (Mobile Unit), 23 (Emergency Room), 33 (Custodial Care facility), 49 (Independent Clinic), 50 (Federally Qualified Health Center), 53 (Community Mental Health Center), 57( Non-Residential Substance Abuse Treatment Facility), 71 (Public Health Clinic), 72 (Rural Health Clinic), 99 (Other Location)

255.003 Acute Crisis Units

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

H0018, U4

Behavioral Health; short-term residential

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Acute Crisis Units provide brief (96 hours or less) crisis treatment services to persons over the age of 18 who are experiencing a psychiatry- and/or substance abuse-related crisis and may pose an escalated risk of harm to self or others. Acute Crisis Units provide hospital diversion and step-down services in a safe environment with psychiatry and/or substance abuse services on-site at all times as well as on-call psychiatry available 24 hours a day. Services provide ongoing assessment and observation; crisis intervention; psychiatric, substance, and co-occurring treatment; and initiate referral mechanisms for independent assessment and care planning as needed.

NOTES

EXAMPLE ACTIVITIES

APPLICABLE POPULATIONS

UNIT

BENEFIT LIMITS

Youth and Adults

Per Diem

* 96 hours or less per encounter

* 1 encounter per month

* 6 encounters per SFY

PROGRAM SERVICE CATEGORY

Crisis Services

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

N/A

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

Acute Crisis Units must be certified by the Division of Provider Services and Quality Assurance as an Acute Crisis Unit Provider

255.004 Substance Abuse Detoxification

CPT®/HCPCS PROCEDURE CODE

PROCEDURE CODE DESCRIPTION

H0014, U4

Alcohol and/or drug services; detoxification

SERVICE DESCRIPTION

MINIMUM DOCUMENTATION REQUIREMENTS

Substance Abuse Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal from alcohol or other drugs. Services help stabilize beneficiaries by clearing toxins from the beneficiary's body. Services are short-term and may be provided in a crisis unit, inpatient, or outpatient setting, and may include evaluation, observation, medical monitoring, and addiction treatment. Detoxification seeks to minimize the physical harm caused by the abuse of substances and prepares the beneficiary for ongoing treatment.

NOTES

EXAMPLE ACTIVITIES

APPLICABLE POPULATIONS

UNIT

BENEFIT LIMITS

Youth and Adults

N/A

* 1 encounter per month

* 6 encounters per SFY

PROGRAM SERVICE CATEGORY

Crisis Services

ALLOWED MODE(S) OF DELIVERY

TIER

Face-to-face

N/A

ALLOWABLE PERFORMING PROVIDERS

PLACE OF SERVICE

Substance Abuse Detoxification must be provided in a facility that is certified by the Division of Provider Services and Quality Assurance as a Substance Abuse Detoxification provider.

21 (Inpatient Hospital), 55 (Residential Substance Abuse Treatment Facility)

256.400 Place of Service Codes

Electronic and paper claims now require the same national place of service codes.

Place of Service

POS Codes

Telemedicine

02

School (Including Licensed Child Care Facility)

03

Homeless Shelter

04

Office (Outpatient Behavioral Health Provider Facility Service Site)

11

Patient's Home

12

Group Home

14

Mobile Unit

15

Temporary Lodging

16

Inpatient Hospital

21

Nursing Facility

32

Custodial Care Facility

33

Independent Clinic

49

Federally Qualified Health Center

50

Inpatient Psychiatric Facility

51

Community Mental Health Center

53

Residential Substance Abuse Treatment Facility

55

Non-Residential Substance Abuse Treatment Facility

57

Public Health Clinic

71

Rural Health Clinic

72

Other

99

Behavioral Health Agency Certification Manual

I. PURPOSE:
A. To assure that Outpatient Behavioral Health Services ("OBHS") care and services provided by certified Behavioral Health Agencies comply v^ith applicable laws, which require, among other things, that all care reimbursed by the Arkansas Medical Assistance Program ("Medicaid") must be provided efficiently, economically, only when medically necessary, and is of a quality that meets professionally recognized standards of health care.
B. The requirements and obligations imposed by §§ l-XIII of this rule are substantive, not procedural.
II. SCOPE:
A. Current Behavioral Health Agency certification under this policy is a condition of Medicaid provider enrollment.
B. Department of Human Services ("DHS") Behavioral Health Agency certification must be obtained for each site before application for Medicaid provider enrollment. An applicant may submit one application for multiple sites, but DHS will review each site separately and take separate certification action for each site.
C. This certification policy applies only to providers in the provision of services in the AR Medicaid fee for service program.
III. DEFINITIONS:
A. "50 mile radius" means 50 miles from a certified site by driving distance. Driving distance is calculated by a method of utilizing a standardized mapping application.
B. "Accreditation" means full accreditation (preliminary, expedited, probationary,

pending, conditional, deferred or provisional accreditations will not be accepted) as an outpatient behavioral health care provider issued by at least one of the following:

* Commission on Accreditation for Rehabilitative Facilities (CARF) Behavioral Health Standards Manual

* The Joint Commission (TJC) Comprehensive Accreditation Manual for Behavioral Health Care

* Council on Accreditation (COA) Outpatient Mental Health Services Manual

Accreditation timing for specific programs is defined in the applicable DHS Certification manual for that program.

C. "Adverse license action" means any action by a licensing authority that is related to client care, any act or omission warranting exclusion under DHS Policy 1088, or that imposes any restriction on the licensee's practice privileges. The action is deemed to exist when the licensing entity imposes the adverse action except as provided in Ark. Code Ann. § 25-15-211(c).
D. "Applicant" means an outpatient behavioral health care agency that is seething DHS

- certification as a Behavioral Heaith Agency. ---------

E. "Certification" means a written designation, issued by DHS, declaring that the provider has demonstrated compliance as declared within and defined by this rule.
F. "Client" means any person for whom a Behavioral Health Agency furnishes, or has agreed or undertaken to furnish, Outpatient Behavioral Health services.
G. "Client Information System" means a comprehensive, integrated system of clinical,

administrative, and flnancial records that provides information necessary and useful to deliver client services. Information may be maintained electronically, in hard copy, or both.

H. "Compliance" means conformance with:
1. Applicable state and federal laws, rules, and regulations including, without limitation:
a. Titles XIX and XXI of the Social Security Act and implementing regulations;
b. Other federal laws and regulations governing the delivery of health care funded in whole or in part by federal funds, for example, 42 U.S.C. § 1320c-5;
c. All state laws and rules applicable to Medicaid generally and to Outpatient Behavioral Health services specifically;
d. Title VI of the Civil Rights Act of 1964 as amended, and implementing regulations;
e. The Americans With Disabilities Act, as amended, and implementing regulations;
f. The Health Insurance Portability and Accountability Act ("HIPAA"), as amended and implementing regulations.
2. Accreditation standards and requirements.
I. "Contemporaneous" means by the end of the performing provider's first worl[LESS THAN] period following the provision of care of services to be documented, or as provided in the Outpatient Behavioral Health Services manual, whichever is longer.
J. "Coordinated Management Plan" means a plan that the provider develops and carries out to assure compliance and quality improvement.
K. "Corrective Action Plan" (CAP) means a document that describes both short- term remedial steps to achieve compliance and permanent practices and procedures to sustain compliance.
L. "Covered Health Care Practitioner" means: Any practitioner providing Outpatient

Behavioral Health Services that is allowable to be reimbursed pursuant to the Outpatient Behavioral Health Services Medicaid Manual.

M. "Cultural Competency" means the ability to communicate and interact effectively with people of different cultures, including people with disabilities and atypical lifestyles. N. "Deficiency" means an item or area of noncompliance.
O. "DHS" means the Arkansas Department of Human Services.
P. "Emergency Behavioral Health Agency services" means nonscheduled Behavioral Health Agency services delivered under circumstances where a prudent layperson with an average knowledge of behavioral health care would reasonably believe that Behavioral Health Agency services are immediately necessary to prevent death or serious impairment of health.
Q. "Medical Director" means a physician that oversees the planning and delivery of all Behavioral Health Agency services delivered by the provider.
R. "Mental health professional" or "MHP" means a person who possesses an Arkansas license to provide clinical behavioral health care. The license must be in good standing and not subject to any adverse license action.
S. "Mobile care" means a face-to-face intervention with the client at a place other than a certified site operated by the provider. Mobile care must be:
1. Either clinically indicated in an emergent situation or necessary for the client to have access to care in accordance with the care plan;
2. Delivered in a clinically appropriate setting; and
3. Delivered where Medicaid billing is permitted if delivered to a Medicaid eligible client.

Mobile care may include medically necessary behavioral health care provided in a school that is within a fifty (50) mile radius of a certified site operated by the provider.

T. "Multi-disciplinary team" means a group of professionals from different disciplines that provide comprehensive care through individual expertise and in consultation with one another to accomplish the client's clinical goals. Multi- disciplinary teams promote coordination between agencies; provide a "checks and balances" mechanism to ensure that the interests and rights of all concerned parties are addressed; and identify service gaps and breakdowns in coordination or communication between agencies or individuals.
U. "NPDB" means the United States Department of Health and Human Services. Health Resources and Services Administration National Provider Data Bank.
V. "Performing provider" means the individual who personally delivers a care or service directly to a client.
W. "Professionally recognized standard of care" means that degree of skill and learning commonly applied under all the circumstances in the community by the average prudent reputable member of the profession. Confomiity with Substance Abuse and Mental Health Services Administration (SAMHSA) evidence-based practice models is evidence of compliance with professionally recognized standards of care.
X. "Provider" means an entity that is certified by DHS and enrolled by DMS as a Behavioral Health Agency
Y. "Qualified Behavioral Health Provider" means a person who:--------------------------
1. Does not possess an Arkansas license to provide clinical behavioral health care;
2. Works under the direct supervision of a mental health professional;
3. Has successfully completed prescribed and documented courses of initial and annual training sufficient to perform all tasks assigned by a mental health professional;
4. Acknowledges in writing that all qualified behavioral health provider services are controlled by client care plans and provided under the direct supervision of a mental health professional.
Z. "Quality assurance (QA) meeting" means a meeting held at least quarterly for systematic monitoring and evaluation of clinic services and compliance. See also, IVtedicaid Outpatient Behavioral Health Services Manual, § 212.000.
AA. "Reviewer" means a person employed or engaged by:
1. DHS or a division or office thereof;
2. An entity that contracts with DHS or a division or office thereof.
BB. "Site" means a distinct place of business dedicated to the delivery of Outpatient

Behavioral Health Services within a fifty (50) mile radius. Each site must be a bona fide Behavioral Health Agency, meaning a behavioral health outpatient ciinic providing all the services specified in this rule and the IVIedicaid Outpatient Behavioral Health Services Manual. Sites may not be adjuncts to a different activity such as a school, a day care facility, a long-term care facility, or the office or clinic of a physician or psychologist.

CC. "Site relocation" means closing an existing site and opening a new site no more than a fifty (50) mile radius from the original site.
DD. "Site transfer" means moving existing staff, program, and clients from one physical location to a second location that is no more than a fifty (50) mile radius from the original site.
EE. "Supervise" as used in this rule means to direct, inspect, observe, and evaluate performance.
FF. "Supervision documentation" means written records of the time, date, subject(s). and duration of supervisory contact maintained in the provider's official records.
IV. COMPLIANCE TIMELINE:
A. Entities currently certified as Rehabilitative Services for Persons with Mental Illness (RSPMI) providers will be grandfathered in as certified Behavioral Health Agencies. Current RSPMI agency recertlfication procedures are based upon national accreditation timelines. Behavioral Health Agency recertification will also be based upon national accreditation timelines.
B. All entities in operation as of the effective date of this rule must comply with this rule within forty-five (45) calendar days in order to maintain certification.
C. DHS may authorize temporary compliance exceptions for new accreditation standards that require independent site surveys and specific service subset accreditations. Such compliance exceptions expire at the end of the provider's accreditation cycle and may not be renewed or reauthorized.
V. APPLICATION FOR DHS BEHAVIORAL HEALTH AGENCY CERTIFICATION:
A. New Behavioral Health Agency applicants must complete DHS BEHAVIORAL HEALTH AGENCY CERTIFICATION Form 100. DHS BEHAVIORAL HEALTH AGENCY FORM 200. and DHS BEHAVIORAL HEALTH AGENCY Form 210
B. DHS BEHAVIORAL HEALTH AGENCY CERTIFICATION Form 100, DHS BEHAVIORAL HEALTH AGENCY FORM 200. and DHS BEHAVIORAL HEALTH AGENCY Form 210 can be found at the following website: wv^w.arkansas.Qov/dhs/dhs
C. Applicants must submit the completed application forms and all required attachments for each proposed site to:

Department of Human Services

Division of Behavioral Health Services

Attn. Certification Office

305 S. Palm

Little Rock, AR 72205

D. Each applicant must be an outpatient behavioral health care agency:
1. Whose primary purpose is the delivery of a continuum of outpatient behavioral health services in a free standing independent clinic;
2. That is independent of any DHS certified Behavioral Health Agency.
E. Behavioral Health Agency certification is not transferable or assignable.
F. The privileges of a Behavioral Health Agency certification are limited to the certified site.
G. Providers may file Medicaid claims only for Outpatient Behavioral Health Services ----- delivered by a perfomiing provider engaged by the provider. -------
H. Applications must be made in the name used to Identify the business entity to the Secretary of State and for tax purposes.
I. Applicants must maintain and document accreditation, and must prominently display certification of accreditation issued by the accrediting organization in a public area at each site. Accreditation must recognize and Include all the applicant's Behavioral Health Agency programs, services, and sites.
1. Initial accreditation must Include an on-site survey for each service site for which provider certification is requested. Accreditation documentation submitted to DHS must list all sites recognized and approved by the accrediting organization as the applicant's service sites.
2. Accreditation documentation must Include the applicant's governance standards for operation and sufficiently define and describe all services or types of care (customer service units or service standards) the applicant intends to provide including, without limitation, crisis intervention/stabilization, in-home family counseling, outpatient treatment, day treatment, therapeutic foster care, intensive outpatient, medication management/pharmacotherapy.
3. Any outpatient behavioral health program associated with a hospital must have a free-standing behavioral health outpatient program national accreditation.
J. The applicant must attach the entity's family involvement policy to each application.
VI. APPLICATION REVIEW PROCESS:
A. Timeline:
1. DHS will review Behavioral Health Agency application fonns and materials within ninety (90) calendar days after DHS receives a complete application package. (DHS will return incomplete applications to senders without review.)
2. For approved applications, a site survey will be scheduled within forty-five (45) calendar days of the approval date.
3. DHS will mail a survey report to the applicant within twenty-five (25) calendar days of the site visit. Providers having deficiencies on survey reports must submit an approvable corrective action plan to DHS within thirty-five (35) calendar days after the date of a survey report.
4. DHS will accept or reject each corrective action plan in writing within twenty (20) calendar days after receipt.
5. Within thirty (30) calendar days after DHS approves a corrective action plan, the applicant must document implementation of the plan and correction of the deficiencies listed in the survey report. Applicants who are unable, despite the exercise of reasonable diligence, to con-ect deficiencies within the time permitted may obtain up to ten (10) additional days based on a showing of good cause.
6. DHS will furnish site-specific certificates via postal or electronic mail within ten (10) calendar days of issuing a site certification.
B. Survey Components: An outline of site survey components is available on the DHS website: www.arkansas.qov/dhs/dhs and is located in appendix # 7.
C. Determinations:
1. Application approved.
2. Application returned for additional information.
3. Application denied. DHS will state the reasons for denial in a written response to the applicant.
VII. DHS Access to Applicants/Providers:
A. DHS may contact applicants and providers at any time;
B. DHS may make unannounced visits to applicants/providers.
C. Applicants/providers shall provide DHS prompt direct access to applicant/provider documents and to applicant/provider staff and contractors, including, without limitation, clinicians, paraprofessionals, physicians, administrative, and support staff.
D. DHS reserves the right to ask any questions or request any additional information related to certification, accreditation, or both.
VllI. ADDITIONAL CERTIFICATION REQUIREMENTS:
A. Care and Services must:
1. Comply with all state and federal laws, rules, and regulations applicable to the furnishing of health care funded in whole or in part by federal funds; to all state laws and policies applicable to Arkansas Medicaid generally, and to Outpatient Behavioral Health Services specifically, and to all applicable Department of Human Services ("DHS") policies including, without limitation, DHS Participant Exclusion Policy § 1088.0.0. The Participant Exclusion Policy is available online at https://dhsshare.arkansas.aov/DHS%20Policies/Forms/Bv%20Policv.aspx
2. Conform to professionally recognized behavioral health rehabilitative treatment models.
3. Be established by contemporaneous documentation that is accurate and demonstrates compliance. Documentation will be deemed to be contemporaneous if recorded by the end of the perfomning provider's first work period following the provision of the care or services to be documented, or as provided in the Outpatient Behavioral Health Services manual, § 252.110, whichever is longer.
B. Applicants and Behavioral Health Agencies must: - ------- -
1. Be a legal entity in good standing;
2. Maintain all required business licenses;
3. Adopt a mission statement to establish goals and guide activities;
4. Maintain a cun'ent organizational chart that identifies administrative and clinical chains of command.
C. Applicants/providers must establish and comply with operating policy that at a minimum implements credible practices and standards for:
1. Compliance;
2. Cultural competence;
3. Provision of services, including refen'al services, for clients that are indigent, have no source of third party payment, or both, including:
a. Procedures to follow when a client is rejected for lack of a third-party payment source or when a client Is discharged for nonpayment of care.
b. Coordinated referral plans for clients that the provider lacks the capacity to provide medically necessary Outpatient Behavioral Health Services. Coordinated referral plans must:
i. Identify in the client record the medically necessary Outpatient Behavioral Health Services that the provider cannot or will not furnish;
ii. State the reason(s) in the client record that the provider cannot or will not furnish the care;
iii. Provide quality-control processes that assure compliance with care, discharge, and transition plans.
IX. STAFFING REQUIREMENTS FOR CERTIFICATION
A. At a minimum, Behavioral Health Agency staffing shall be sufficient to establish and implement services for each Behavioral Health Agency client, and must include the following:
1. Chief Executive Officer/Executive Director (or functional equivalent) (full-time position or full-time equivalent positions): The person or persons identified to carry out CEO/ED functions:
a. Is/are ultimately responsible for applicant/provider organization, staffing, policies and practices, and Behavioral Health Agency service delivery;
b. Must possess a master's degree in behavioral healtti care, management, or a related field and experience, and meet any additional qualifications required by the provider's governing body. Other job- related education, experience, or both, may be substituted for all or part of these requirements upon approval of the provider's governing body.
2. Clinical Director (or functional equivalent) (full-time position or full-time equivalent positions): The person or persons identified to carry out clinical director functions must:
a. Report directly to the CEO/ED;
b. Be the DHS contact for clinical and practice-related issues;
c. Be accountable for all clinical services (professional and paraprofessional);
d. Be responsible for Behavioral Health Agency care and service quality and compliance;
e. Assure that all services are provided within each practitioner's scope of practice under Arkansas law and under such supervision as required by law for practitioners not licensed to practice independently;
f. Assure and document in the provider's official records the direct supervision of MHP's, either personally or through a documented chain of supervision.
g. Assure that licensed mental health professionals directly supervise Qualified Behavioral Health Providers. Direct supervision ratios must not exceed one licensed mental health professional to ten (10) Qualified Behavioral Health Providers;
h. Possess independent Behavioral Health licensure in Arkansas as a Licensed Psychologist, Licensed Certified Social Worker, (LCSW), Licensed Psychological Examiner - Independent (LPE-I), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), or an Advanced Practice Nurse or Clinical Nurse Specialist (APN or CNS) with a specialty in psychiatry or mental health and a minimum of two years clinical experience post master's degree.
3. Mental Health Professionals (Independently Licensed Clinicians, Non-Independently Licensed Clinicians):
a. MHP's may:
i. Provide direct behavioral health care;
ii. Delegate and oversee work assignments of Qualified Behavioral Health Provider's;
iii. Delegate and oversee work assignments of Certified Peer Specialists, Certified Youth Support Specialists, and Certified Family Support Partners
iv. Ensure compliance and confonmity to the provider's policies and ~ procedures;
v. Provide direct supervision of Qualified Behavioral Health Provider's;
vi. Provider direct supervision of Certified Peer Specialists, Certified Youth Support Specialists, and Certified Family Support Partners
vii. Provide case consultation and in-service training;
viii. Observe and evaluate performance of Qualified Behavioral Health Provider's.
ix. Observe and evaluate performance of Certified Peer Specialists, Certified Youth Support Specialists, and Certified Family Support Partners
b. MHP Supervision:
i. Communication between an MHP and the MHP's supervisor must include each of the following at least every twelve (12) months:
1. Assessment and referral skills, including the accuracy of assessments;
2. Appropriateness of treatment or service interventions in relation to the client needs;
3. Treatment/intervention effectiveness as reflected by the client meeting individual goals;
4. Issues of ethics, legal aspects of clinical practice, and professional standards;
5. The provision of feedback that enhances the skills of direct service personnel;
6. Clinical documentation issues identified through ongoing compliance review;
7. Cultural competency issues;
8. All areas noted as deficient or needing improvement.
ii. Documented client-specific face-to-face and other necessary communication regarding client care must occur between each MHP's supervisor and the MHP periodically (no less than every ninety (90) calendar days) in accordance with a schedule maintained in the provider's official records.
4. Qualified Behavioral Health Providers (including Certified Peer Support

Specialist,):

a. Are MHP service extenders;
b. Qualified Behavioral Health Provider supervision must conform to the requirements for MHP supervision (See § IX (3){b)) except that all requirements must be met every six (6) months, and one or more licensed health care professional(s) acting within the scope of his or her practice must have a face-to-face contact with each Qualified Behavioral Health Provider for the purpose of clinical supervision at least every fourteen (14) days, must have at least twelve (12) such face-to-face contacts every ninety (90) days, and such additional face-to-face contacts as are necessary in response to a client's unscheduled care needs, response or lack of response to treatment, or change of condition;
c. Providers must establish that Qualified Behavioral Health Provider supervision occurred via individualized written certifications created by a licensed mental health professional and filed in the provider's official records on a weekly basis, certifying:
i. That the licensed mental health professional periodically (in accordance with a schedule tailored to the client's condition and care needs and previously recorded in the provider's official records) communicated individualized client-specific instructions to the mental health paraprofessional describing the manner and methods for the delivery of paraprofessional services;
ii. That the licensed mental health professional periodically (in accordance with a schedule tailored to the client's condition and care needs and previously recorded in the provider's official records, but no less than every 30 days) personally observed the mental health paraprofessional delivering services to a client; that the observations were of sufficient duration to declare whether paraprofessional services complied with the licensed mental health professional's instructions;
iii. The date, time, and duration of each supervisory communication with and observation of a Qualified Behavioral Health Provider.
d. The Behavioral Health Agency is responsible for ensuring Qualified Behavioral Health Providers that are not certified as Certified Peer Support Specialists, successfully complete training in behavioral health services provision from a licensed medical person experienced in the area of behavioral health, a certified Behavioral Agency, or a facility licensed by the State Board of Education before providing care to Medicaid beneficiaries.
i. The Qualified Behavioral Health Provider must receive orientation to the Behavioral Health Agency.
ii. The Qualified Behavioral Health Provider training course offered for those individuals not certified as Certified Peer Support Specialist, must total a minimum of forty (40) classroom hours and must be successfully completed within a maximum time of the first two (2) months of employment by the Behavioral Health Agency.
iii. The training curriculum must contain information specific to the population being served, i.e. adult, dually diagnosed, etc. The cumculum must include, but is not limited to:
1. Communication skills.
2. Knowledge of behavioral health illnesses.
3. How to be an appropriate role model.
4. Behavior management.
5. Handling emergencies.
6. Record keeping: observing beneficiary, reporting or recording observations, time, or employment records.
7. Knowledge of clinical limitations.
8. Knowledge of appropriate relationships with beneficiary.
9. Group interaction.
10. Identification of real issues.
11. Listening techniques.
12. Confidentiality.
13. Knowledge of medications and side effects.
14. Daily living skills.
15. Hospitalization procedures single-point-of-entry.
16. Knowledge of the Supplemental Security Income (SSI) application process.
17. Knowledge of day treatment models proper placement levels.
18. Awareness of options.
19. Cultural competency.
20. Ethical issues in practice.
21. Childhood development, if serving the child and adolescent population.
iv. A written examination of the Qualified Behavioral Health Provider's that are not certified as Certified Peer Support Specialists, knowledge of the 40-hour classroom training curriculum must be successfully completed.
v. Evaluation of the Qualified Behavioral Health Provider's ability to perfomn daily living skills (DLS) for mental health sen/ices must be successfully completed by means of a skills test.
vi. The Qualified Behavioral Health Provider who successfully completes the training must be awarded a certificate. This certificate must state the person is qualified to work in an agency under professional supervision as a Qualified Behavioral Health Provider.
vii. In-service training sessions are required at a minimum of once per 12-month period after the successful completion of the initial 40-hour classroom training for Qualified Behavioral Health Specialists not certified as Certified Peer Support Specialist, The in-service training must total a minimum of eight (8) hours each 12-month period beginning with the date of certification as a Qualified Behavioral Health Provider and each 12-month period thereafter.

The in-service training may be conducted, in part, in tiie field. Documentation of in-service hours will be maintained in the employee's personnel record and will be available for inspection by regulatory agencies.

5. Corporate Compliance Officer:
a. Manages policy, practice standards and compliance, except compliance that is the responsibility of the medical records librarian;
b. Reports directly to the CEO/ED (except in circumstances where the compliance officer is required to report directly to a director, the board of directors, or an accrediting or oversight agency);
c. Has no direct responsibility for billings or collections;
d. Is the DHS and Medicaid contact for DHS certification, Medicaid enrollment, and compliance.
6. lUledical Director:
a. Oversees Behavioral Health Agency care planning, coordination, and delivery, and specifically:
i. Diagnoses, treats, and prescribes for behavioral illness;
ii. Is responsible and accountable for all client care, care planning, care coordination, and medication storage;
iii. Assures that physician care is available 24 hours a day, 7 days a week;
iv. May delegate client care to other physicians, subject to documented oversight and approval;
v. Assures that a physician participates in treatment planning and reviews;
vi. If the medical director is not a psychiatrist, a psychiatrist certified by one of the specialties of the American Board of Medical Specialties must serve as a consultant to the medical director and to other staff, both medical and non-medical. If the provider serves clients under the age of twenty-one (21), the medical director shall have access to a board certified child psychiatrist, for example, through the Psychiatric Research Institute child/Adolescent Telephone Consultation Service;
vii. Medical director services may be acquired by contract.
b. If the medical director is not a psychiatrist then the medical director shall contact a consulting psychiatrist within twenty-four (24) hours in the following situations:
i. When antipsychotic or stimulant medications are used in dosages higher than recommended in guidelines published by the Arkansas Department of Human Services Division of Medical Services;
ii. When two (2) or more medications from the same pharmacological class are used;
iii. When there is significant clinical deterioration or crisis with enhanced risk of danger to self or others.
c. The consulting psychiatrist(s) shall participate in quarterly quality assurance meetings.
7. Privacy Officer: Develops and implements policies to assure compliance with privacy laws, regulations, and rules. Applicants/providers may assign privacy responsibilities to the Corporate Compliance Officer, Grievance OfTicer, or Medical Records Librarian, but not the CEO/ED.
8. Quality Control lUlanager: Chairs the quality assurance committee and develops and implements quality control and quality improvement activities. Applicants/providers may assign quality control manager responsibilities to the Corporate Compliance Officer or Medical Records Manager, but not the CEO/ED.
9. Grievance Officer:
a. Develops and implements the applicant's/provider's employee and client grievance procedures.
b. Effectively communicates grievance procedures to staff, contractors, prospective clients, and clients. Communications to clients who are legally incapacitated shall include communication to the client's responsible party.
c. The grievance officer shall not have any duties that may cause him/her to favor or disfavor any grievant.
10. iVIedical Records Librarian:
a. Must be qualified by education, training, and experience to understand and apply:
i. Medical and behavioral health terminology and usages covering the full range of services offered by the provider;
ii. Medical records forms and formats;
iii. Medical records classification systems and references such as The American Psychiatric Association's Diagnostic and Statistical Manual -IV-TR (DSM-IV-TR) and subsequent editions. International Classification of Diseases (ICD), Diagnostic Related Groups (DRG's), Physician's Desk Reference (PDR), Current Procedural Terminology (CPT), medical dictionaries, manuals, textbooks, and glossaries.
iv. Legal and regulatory requirements of medical records to assure the record is acceptable as a legal document;
v. Laws and regulations on the confidentiality of medical records (Privacy Act and Freedom of Information Act) and the procedures for informed consent for release of information from the record.
vi. The interrelationship of record services with the rest of the facility's services.
b. Develops and implements:
i. The client information system;
ii. Operating methods and procedures covering all medical records functions.
iii. Insures that the medical record is complete, accurate, and compliant.
11. Licensed Psychologist, Licensed Psychological Examiner (LPE), or Licensed Psychological Examiner - Independent (LPE-I):
a. Provides psychological evaluations;
b. Each licensed psychological examiner or licensed psychological examiner-l must have supervision agreements with a doctoral psychologist to provide appropriate supervision or services for any evaluations or procedures that are required under or are outside the psychological examiner's scope of independent practice. Documentation of such agreements and of all required supervision and other practice arrangements must be included in the psychological examiner's personnel record;
c. Services may be acquired by contract
B. Multidisciplinary Team(s): Any client identified as Tier 2 by the independent assessment shall be assigned a multidisciplinary team that includes professionals and qualified behavioral health providers as necessary to ensure coordination of each client's Outpatient Behavioral Health Services. All Tier 2 clients require the development of a Master Treatment Plan with ongoing reviews at least every one-hundred and eighty (180) calendar days.

For clients not eligible for Rehabilitative (Tier 2) Level or Intensive (Tier 3) Level services, he services offered in the Counseling Level (Tier 1) are a limited array of counseling services provided by a master's level clinician. Establishment of goals and a plan to reach those goals is part of good clinical practice and can be developed with the client during the Mental Health Diagnostic Assessment and Interpretation of Diagnosis. Clinicians should assess client's response to treatment at each session which should include a review of progress towards mutually agreed upon goals.

C. Quality Assurance Meetings:

Each provider must hold a quarterly quality assurance meeting.

D. Health Care Professional Notification/Disqualification:
1. Notice of covered health care practitioners:
a. Within twenty (20) days of the effective date of this rule, applicants/providers must notify the Office of Medicaid Inspector General (OMIG) of the names of covered health care practitioners wUo are providing Outpatient Behavioral Health Services.
b. On or before the tenth day of each month, providers must notify the Office of Medicaid Inspector General (OMIG) of the names of all covered health care practitioners who are providing Outpatient Behavioral Health Services and whose names were not previously disclosed.
2. Licensed health care professionals may not furnish Outpatient Behavioral Health Services during any time the professional's license is subject to adverse license action.
3. Applicants/providers may not employ/engage a covered health care practitioner after learning that the practitioner:
a. Is excluded from Medicare, Medicaid, or both;
b. Is debarred under Ark. Code Ann. § 19-11 -245;
c. Is excluded under DHS Policy 1088; or d. Was subject to a final determination that the provider failed to comply with professionally recognized standards of care, conduct, or both. For purposes of this subsection, "final determination" means a final court or administrative adjudication, or the result of an alternative dispute resolution process such as arbitration or mediation.
E. Applicants/providers must maintain documentation identifying the primary work location of all mental health professionals and qualified behavioral health providers providing services on behalf of the Behavioral Health Agency.
F. Providers must maintain copies of disclosure forms signed by the client, or by the client's parent or guardian before Outpatient Behavioral Health Services are delivered except in emergencies. Such forms must at a minimum:
1. Disclose that the services to be provided are Outpatient Behavioral Health Services;
2. Explain Outpatient Behavioral Health Services eligibility, SED and SMI criteria;
3. Contain a brief description of the Behavioral Health Agency services;
4. Explain that all Outpatient Behavioral Health Services care must be medically necessary;
5. Disclose that third party (e.g., Medicaid or insurance) Outpatient Behavioral Health Service payments may be denied based on the third party payer's policies or ailes;
6. Identify and define any services to be offered or provided in addition to those offered by the Behavioral Health Agency, state whether there will be a charge for such services, and if so, document payment an-angements;
7. Notify that services may be discontinued by the client at any time;
8. Offer to provide copies of Behavioral Health Agency and Outpatient Behavioral Health Services rules;
9. Provide and explain contact information for making complaints to the provider regarding care delivery, discrimination, or any other dissatisfaction with care provided by the Behavioral Health Agency;
10. Provide and explain contact infomnation for making complaints to state and federal agencies that enforce compliance under § 111(G)(1).
G. Outpatient Behavioral Health Services maintained at each site must include:
1. Psychiatric Evaluation and Medication Management;
2. Outpatient Services, including individual and family therapy at a minimum;
3. Crisis Services.
L. Providers must tailor all Outpatient Behavioral Health Services care to individual client need. If client records contain entries that are materially identical, DHS and the Division of Medical Services will, by rebuttable presumption, that this requirement is not met.
M. Outpatient Behavioral Health Services for individuals under age eighteen (18): Providers must establish and Implement policies for family identification and engagement in treatment for persons under age eighteen (18), including strategies for identifying and overcoming barriers to family involvement.
N. Emergency Response Services: Applicants/providers must establish, implement, and maintain a site-specific emergency response plan, which must include:
1. A 24-hour emergency telephone number;
2. The applicant/provider must:
a. Provide the 24-hour emergency telephone number to all clients;
b. Post the 24-hour emergency number on all public entries to each site;
c. Include the 24-hour emergency phone number on answering machine greetings;
d. Identify local law enforcement and medical facilities wittiin a 50-mile radius that - - may be emergency responders to client emergencies.
3. Direct access to a mental health professional within fifteen (15) minutes of an emergency/crisis call and face-to-face crisis assessment within two (2) hours;
4. Response strategies based upon:
a. Time and place of occurrence;
b. Individual's status (client/non-client);
c. Contact source (family, law enforcement, health care provider, etc.).
5. Requirements for a face-to-face response to requests for emergency intervention received from a hospital or law enforcement agency regarding a current client.
6. All face-to-face emergency responses shall be:
a. Available 24 hours a day, 7 days a week;
b. Made by a mental health professional within two (2) hours of request (unless a different time frame is witiiin clinical standards guidelines and mutually agreed upon by the requesting party and the MHP responding to the call).
7. Emergency services training requirements to ensure that emergency service are age-appropriate and comply with accreditation requirements. Providers shall maintain documentation of all emergency service training in each trainee's personnel file.
8. Requirements for clinical review by the clinical supervisor or emergency services director within 24 hours of each after-hours emergency intervention with such additional reporting as may be required by the provider's policy.
9. Requirements for documentation of all crisis calls, responses, collaborations, and outcomes;
10. Requirements that emergency responses not vary based on the client's funding source. If a client is eligible for inpatient behavioral health care funded through the community mental health centers and the provider is not a community mental health center with access to these funds, the provider must:
a. Determine whether the safest, least restrictive altemative is psychiatric hospitalization; and
b. Contact the appropriate community mental health center (CMHC) for consult and to request the CMHC to access local acute care funds for those over 21.
O. Each applicant/provider must establish and maintain procedures, competence, and capacity;
1. For assessment and individualized care planning and delivery;
2. For discharge planning integral to treatment;
3. For mobile care;
4. To assure that each mental health professional makes timely clinicai disposition decisions;
5. To make timely referrals to other services;
6. To refer for inpatient services or less restrictive alternative;
7. To identify clients v\/ho need direct access to clinical staff, and to promptly provide such access.
P. Each applicant/provider must establish, maintain, and document a quality improvement program, to include:
1. Evidence based practices;
2. Use of agency wide outcomes measures to improve both client care and clinical practice that are approved by the agency's national accrediting organization. The following must be documented:
a. Measured outcomes
b. Sample report
c. Collection of outcomes, beginning at the initial mental health diagnosis service, which would be completed very close to the client's intake.
3. Requirements for informing all clients and clients' responsible parties of the client's rights while accessing services.
4. Regular (at least quarterly) quality assurance meetings that include:
a. Clinical Record Reviews: medical record reviews of a minimum number of randomly selected charts. The minimum number is the lesser of a statistically valid sample yielding 95% confidence with a 5% margin of error; or 10% of all charts open at any time during the past three (3) months;
b. Program and services reviews that:
i. Assess and document whether care and services meet client needs;
ii. Identify unmet behavioral health needs;
iii. Establish and implement plans to address unmet needs.
X. HOME OFFICE:
A. Each provider must maintain and identify a home office in the State of Arkansas;
B. The home office may be located at a site or may be solely an administrative office not requiring site certification;
C. The home office is solely responsible for governance and administration of all of the provider's Arkansas sites;
D. Home office governance and administration must be documented in a coordinated management plan;
E. The home office shall establish policies for maintaining client records, including policies designating where the original records are stored.
XI. SITE REQUIREMENTS
A. All sites must be located in the State of Arkansas;
B. Accreditation documentation must specifically include each site.
XII. SITE RELOCATION. OPENING, AND CLOSING (Note: temporary service disruptions caused by inclement weather or power outages are not "closings.")
A. Planned Closings:
1. Upon deciding to close a site either temporarily or pemianently, the provider immediately must provide written notice to clients, DHS, the Division of Medical Services, the Medicaid fiscal agent, and the accrediting organization.
2. Notice of site closure must state the site closure date;
3. If site closure is permanent, the site certification expires at 12:00 a.m. the day following the closure date stated in the notice;
4. If site closing is temporary, and is for reasons unrelated to adverse governmental action, DHS may suspend the site certification for up to one (1) year if the provider maintains possession and control of the site. If the site Is not operating and in compliance within the time specified in the site certification suspension, the site certification expires at 12:00 a.m. the day after the site certification suspension ends.
B. Unplanned Closings:
1. If a provider must involuntarily close a site due to, for example, fire, natural disaster, or adverse governmental action, the provider must immediately notify clients and families, DHS, the Division of Medical Services, the Medicaid ^scal agent, and the accrediting organization of the closure and the reason(s) for the closure.
2. Site certification expires in accordance with any pending regulatory action, or, if no regulatory action is pending, at 12:00 a.m. the day following permanent closure.
C. All Closings:
1. Providers must assure and document continuity of care for all clients who receive Outpatient Behavioral Health Services at the site;
2. Notice of Closure and Continuing Care Options:
a. Providers must assure and document that clients and families receive actual notice of the closure, the closure date, and any information and instructions necessary for the client to obtain transition services;
b. After documenting that actual notice to a specific client was impossible despite the exercise of due diligence, providers may satisfy the client notice requirement by mailing a notice containing the information described in subsection (a), above, to the last known address provided by the client; and c. Before closing, providers must post a public notice at each site entry. The public notice must include the name and contact information for all Behavioral Health Agencies within a fifty (50) mile radius of the site.
3. An acceptable transition plan is described below:

Transition Plan:

1. Identify and list all certified sites within a 50 mile radius. Include telephone numbers and physical addresses on the list.
2. Provide clients/families with the referral information and have them sign a transfer of records form/release of information to enable records to be transferred to the provider of their choice.
3. Transfer records to the designated provider.___________________________________
4. Designate a records retrieval process as specified in Section i of tlie Arlcansas {Medicaid Outpatient Behaviorai Health Services Provider Poiicy Manuai § 142.300. ~
5. Submit a reporting of transfer to DHS (Attn: Poiicy & Certification Office) including a list of client names and the disposition of each referral. See example below:

Name

Referred to:

Records Transfer Status:

RX Needs Met By:

Johnny

OP Provider Name

to be delivered 4/30/20XX

Provided 1 month RX

Mary

Private Provider Name

Delivered 4/28/20XX

No Meds

Judy

Declined Referral

XX

6. DHS may require additional information regarding documentation of client transfers to ensure that client needs are addressed and met._________________________________

DHS BEHAVIORAL HEALTH AGENCY Form 220 shall be used when a site is to be closed.

D. New Sites: Use DHS BEHAVIORAL HEALTH AGENCY Form 250 to apply for new sites, which would include a new Medicaid provider ID number for that site,
E. Site Transfer:
1. At least forty-five (45) calendar days before a proposed transfer of an accredited site. the provider must apply to DHS to transfer site certification. The application must include documentation that:
a. The provider notified the accrediting entity, and the accrediting entity has extended or will extend accreditation to the second site; or
b. The accrediting entity has established an accreditation timeframe.
2. The provider must notify clients and families, DHS, the Division of IVIedical Services, the {Medicaid fiscal agent, and the accrediting organization at least thirty (30) calendar days before the transfer;
3. DHS does not require an on-site survey, nor does the Division of IWedicai Services require a new IWedicaid provider number. Please use DHS BEHAVIORAL HEALTH AGENCY Form 220 for a site move or transfers.
F. Site Relocation: The provider must follow the rules for closing the original site, and the rules for opening a new site.
XIII. PROVIDER RE-CERTIFICATION:
A. The term of DHS site certification is concurrent with the provider's national accreditation cycle, except that site certification extends six (6) months past the accreditation expiration month if there is no inten'uption in the accreditation. (The six-month extension is to give the Behavioral Health Agency time to receive a final report from the accrediting organization, which the provider must immediately forward to DHS.)
B. Providers must furnish DHS a copy of:
1. Correspondence related to the provider's request for re-accreditation:
a. Providers shall send DHS copies of correspondence from the accrediting agency within five (5) business days of receipt;
b. Providers shall furnish DHS copies of correspondence to the accrediting organization concurrently with sending originals to the accrediting organization.
2. An application for provider and site recertiflcatlon:
a. DHS must receive provider and site recertiflcatlon applications at least fifteen (15) business days before the DHS Behavioral Health Agency certification expiration date;
b. The Re-Certification form with required documentation is DHS BEHAVIORAL HEALTH AGENCY Form 230 and is available at vtfww.arkansas.aov/dhs/dhs.
C. If DHS has not recertified the provider and site(s) before the certification expiration date, certification is void beginning 12:00 a.m. the next day.
XIV. MAINTAINING DHS BEHAVIORAL HEALTH AGENCY CERTIFICATION:
A. Providers must:
1. Maintain compliance;
2. Assure that DHS certification information is current, and to that end must notify DHS within thirty (30) calendar days of any change affecting the accuracy of the provider's certification records;
3. Furnish DHS all con-espondence in any form (e.g., letter, facsimile, email) to and from the accrediting organization to DHS within thirty (30) calendar days of the date the correspondence was sent or received except:
a. As stated in § XII;
b. Correspondence related to any change of accreditation status, which providers must send to DHS within three (3) calendar days of the date the correspondence was sent or received.
c. Correspondence related to changes in service delivery, site location, or organizational structure, which providers must send to DHS within ten (10) calendar days of the date the correspondence was sent or received.
4. Display the Behavioral Health Agency certificate for each site at a prominent public location within the site
B. Annual Reports:
1. Providers must furnish annual reports to DHS before July 1 of each year that the provider has been in operation for the preceding twelve (12) months. Community l\^ental Health Centers and specialty clinics may meet this requirement by submitting the Annual Plan/Basic Services Plan to DHS.
2. Annual report shall be prepared by completing forms provided by DHS. Please use DHS BEHAVIORAL HEALTH AGENCY Fomfi 240 for the Behavioral Health Agency annual report.
XV. NONCOMPLIANCE
A. Failure to comply with this rule may result in one or more of the following:
1. Submission and implementation of an acceptable con-ective action plan as a condition of retaining Behavioral Health Agency certification;
2. Suspension of Behavioral Health Agency certification for either a fixed period or until the provider meets all conditions specified in the suspension notice;
3. Termination of Behavioral Health Agency certification.
XVI APPEAL PROCESS
A. If DHS denies, suspends, or revokes any Behavioral Health Agency certification (takes adverse action), the affected proposed provider or provider may appeal the DHS adverse action. Notice of adverse action shall comply with Ark. Code Ann. §§ 20-77-1701 -1705, and §§1708-1713. Appeals must be submitted in writing to the DHS. The provider has thirty (30) calendar days from the date of the notice of adverse action to appeal. An appeal request received within thirty-five (35) calendar days of the date of the notice will be deemed timely. The appeal must state with particularity the error or errors asserted to have been made by DHS in denying certification, and cite the legal authority for each assertion of error. The provider may elect to continue Medicaid billing under the Behavioral Health Agency program during the appeals process. I f the appeal is denied, the provider must return all monies received for Behavioral Health Agency services provided during the appeals process.
B. Within thirty (30) calendar days after receiving an appeal DHS shall:
(1) designate a person who did not participate in reviewing the application or in the appealed-from adverse decision to hear the appeal;
(2) set a date for the appeal hearing;
(3) notify the appellant in writing of the date, time, and place of the hearing. The hearing shall be set within sixty (60) calendar days of the date DHS receives the request for appeal, unless a party to the appeal requests and receives a continuance for good cause.
C. DHS shall tape record each hearing.
D. The hearing official shall issue the decision within forty-five (45) calendar days of the date that the hearing record is completed and closed. The hearing official shall issue the decision in a written document that contains findings of fact, conclusions of law, and the decision. The findings, conclusions, and decision shall be mailed to the appellant except that if the appellant is represented by counsel, a copy of the findings, conclusions, and decision shall also be mailed to the appellant's counsel. The decision is the final agency determination under the Administrative Procedure Act.
E. Delays caused by the appealing party shall not count against any deadline. Failure to issue a decision within the time required is not a decision on the merits and shall not alter the rights or status of any party to the appeal, except that any party may pursue legal process to compel the hearing official to render a decision.
F. Except to the extent that they are inconsistent with this policy, the appeal procedures in the Arkansas Medicaid Outpatient Behavioral Health Services Provider Manual are incorporated by reference and shall control.

Notes

016.19.18 Ark. Code R. § 003
10/26/2018

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.


No prior version found.