Substance
Abuse
Family
Evaluation
Preferred Practice Standards
Key Contact Information .............................................................................................5
Welcome to Project SAFE ........................................................................................6
History........................................................................................................................6
Program Overview .....................................................................................................6
Project S.A.F.E Covered Services ............................................................................7
Evaluation ______________________________________________ 8
Adolescent Evaluation: .............................................................................................................. 9
Comprehensive Evaluation: ........................................................................................................ 9
Individual Therapy _______________________________________ 10
Group Therapy __________________________________________ 10
Family Therapy _________________________________________ 10
Intensive Outpatient Therapy (IOP) __________________________ 10
Partial Hospitalization Program (PHP) ______________________ 10
Urine Drug Screens ______________________________________ 11
Hair Testing ____________________________________________ 11
Treatment Levels of Care __________________________________ 11
Service Limitations and Exclusions __________________________ 12
Level of Care Guide (Table I) ................................................................................13
Level I: (SA I.1 & SA I.1) Outpatient _________________________ 13
Level of Care Guide (Table II) ...............................................................................14
Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP) _________ 14
Level of Care Guide (Table III) ..............................................................................15
Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening ____ 15
Referral and Authorization Process .......................................................................16
Service Authorization and Referral Process for Covered Services .......................17
Referral and Authorization Process (CHART)......................................................23
Type of Service/Level of Care ______________________________ 23
Information Needed From DCF _____________________________ 23
Information Need from the Provider _________________________ 23
Information needed or provided by ABH ______________________ 23
Authorization Requirements ________________________________ 23
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Reimbursement Protocol ...................................................................................24
Provider Credentialing ............................................................................................25
Reimbursement ........................................................................................................25
Reimbursement for Evaluation ..............................................................................26
DCF Responsibilities ___________________________________ 26
Provider Responsibilities _______________________________ 26
ABH Project S.A.F.E. Will ______________________________ 26
Reimbursement for Treatment ...................................................................................27
DCF Responsibilities ___________________________________ 27
Provider Responsibilities _______________________________ 27
ABH Project S.A.F.E. Will ______________________________ 28
Reimbursement for IOP or PHP Levels of Care .........................................................29
DCF Responsibilities ___________________________________ 29
Provider Responsibilities _______________________________ 29
ABH Project S.A.F.E. Will ______________________________ 29
Reimbursement for Hair Testing ................................................................................30
DCF Responsibilities ___________________________________ 30
Provider Responsibilities _______________________________ 30
ABH Project S.A.F.E. Will ______________________________ 30
Reimbursement for Random Urine Drug Screens Only ..............................................31
DCF Responsibilities ___________________________________ 31
Provider Responsibilities _______________________________ 31
ABH Project S.A.F.E. Will ______________________________ 31
Requests for Court Cost Reimbursement ....................................................................33
DCF Responsibilities ___________________________________ 33
Provider Responsibilities _______________________________ 33
ABH Project S.A.F.E. Will ______________________________ 33
Special Exceptions ..................................................................................................34
Six Tab Web Base Claim System ............................................................................36
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Complaints, Grievances, and Appeals ...........................................................38
Appendix A ...........................................................................................................42
CLIENT REFERRAL FORM (page 1) ________________________ 42
CLIENT REFERRAL FORM (page 2) ________________________ 43
Appendix B ..............................................................................................................44
CLIENT REPORT FORM ____________________________________ 44
PROJECT SAFE.....................................................................................................44
Appendix C ...........................................................................................................45
Needs Assessment Form _____________________________________ 45
Appendix D ..............................................................................................................46
TANF ELIGIBILITY SCREENING FORM ____________________ 46
Appendix E: Outpatient Treatment Request Downloading Procedure ...............47
Outpatient Treatment Request Downloading Procedure (page 2) __ 48
Outpatient Treatment Request Downloading Procedure (page 3) _________ 49
Appendix G ..............................................................................................................51
Special Exception _________________________________________ 51
FAQ for Project SAFE Special Exceptions ...........................................................52
(Formerly Regional Administrator’s Approval) ________________ 52
Appendix H: ............................................................................................................54
Screen Shot of Web-Based Claims System _____________________ 54
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Key Contact Information
Advanced Behavioral Health
213 Court Street
Middletown, CT 06457
Referral Hotline:…………………………1-800-272-0097
Main Number:……………………………1-860-638-5309
Billing Department……………………….1-860-704-6144
Fax:………………………………………..1-860-638-5302
Advanced Behavioral Health Website:
https://www.abhct.com/
Online access to information and materials, such as newsletters, alert memos,
and forms.
Department of Children and Families Website:
http://www.state.ct.us/dcf/
Online access to a wide variety of information related to the Department of
Children and Families such as newsletters, other publications, and forms.
Department of Mental Health and Addiction Services Website:
http://www.dmhas.state.ct.us/
Online access to a wide variety of information related to the Department of
Mental Health and Addiction Services such as newsletters, publications, and
forms.
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Welcome to Project SAFE
Welcome to the Advanced Behavioral Health (ABH) Project S.A.F.E. Provider network. As a
member of the Project S.A.F.E. Provider network you have joined a group of highly respected
behavioral health professionals. We recognize that you share our commitment to improve the
quality of life for clients by providing a continuum of high quality accessible behavioral health
care services.
This Preferred Practice Standards handbook has been developed to inform you of standard
practice of participants in the ABH Project S.A.F.E. network The handbook begins with an
introduction, states policies and procedures for referral, authorization, claims submission, and the
complaints, grievances, and appeal process. Finally, the necessary forms are included, along
with a glossary and index for your convenience. Services provided for ABH Project S.A.F.E.
clients must be consistent with the practices encompassed in this handbook Should you have any
questions, please contact ABH Project S.A.F.E. at:
1-800-272-0097
History
The Department of Children and Families (DCF) initiated Project S.A.F.E. (Substance Abuse
Family Evaluation) in 1995 as a way to connect its child protection system with the adult
substance abuse treatment system. DCF contracted with ABH to coordinate central intake and
priority access to drug screening, evaluation, and ambulatory treatment for substance abusing
primary caregivers of children receiving protective services. DCF began collaborating with the
Department of Mental Health and Addiction Services (DMHAS) in October 1999 to identify and
address more effectively substance abuse issues and to coordinate and blend state, federal, and
private resources to meet the needs of these populations.
Program Overview
Project S.A.F.E. is a program, jointly funded by DCF and DMHAS, designed to provide priority
access to substance abuse evaluation and outpatient treatment services. Clients are eligible for
Project S.A.F.E. services if they meet the following criteria:
 Parents or Primary Caregiver involved in child Protective Services
 The completed DCF Substance Abuse Screen has identified that substance use/abuse may be
effecting the ability to parent effectively and substance abuse treatment or further evaluation
is needed;
 A Referral has been made by DCF Social Worker prior to any treatment and \or evaluation
service
Funding for Project S.A.F.E. services is provided by DCF and DMHAS, and administered by
ABH. This funding system is designed as a payer of last resort. The term ‘payer of last resort’
indicates that the Project S.A.F.E. funds are used to reimburse providers on a fee-for-service
basis when there is no other source of reimbursement available.
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Project S.A.F.E. Covered Services
There are a variety of services that are reimbursed under Project S.A.F.E.’s payer of last resort
system. In the following section, we will outline identify and define all services covered by
Project SAFE.
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Project S.A.F.E Covered Services
There are eight basic treatment services that are reimbursable within Project S.A.F.E.
 Evaluation
 Individual Therapy (SA I.1)
 Group Therapy (SA I.1)
 Family Therapy (SA I.1)
 Intensive Outpatient Therapy (IOP) (SA II.1)
 Partial Hospitalization Program (PHP) (SA II.5)
 Urine Drug Screens
 Hair Testing
The following section contains a description of these services.
Evaluation
Clients are referred for a Project S.A.F.E evaluation because the DCF Social Worker has
completed the DCF substance abuse screen (DCF form 2110) and found reason to believe that
the individual’s ability to parent effectively is impaired as a result of his/her use. The evaluation
is conducted by an approved Project S.A.F.E Provider and consists of a bio-psycho-social
assessment focusing on the following areas:
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Demographic Information
Family composition and history
Substance abuse history
Trauma history
Medical history and current medical status
DSM IV TR Diagnostic formulation
Drug screen results
Summary and recommendations
Each evaluation should contain a written narrative in the aforementioned areas.
Once the evaluation is completed by the provider, the results of the evaluation should be
verbally communicated to the DCF Social Worker within twenty-four (24) hours (one business
day) of its completion. A written clinical summary will be forwarded to both the Social Worker
and the DCF Substance Abuse Specialist within five (5) business days of the evaluation.
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In specific cases there are two different evaluation subtypes that may be completed. They are an
adolescent evaluation or a comprehensive evaluation.
Adolescent Evaluation:
Project S.A.F.E. also has capacity to conduct adolescent specific evaluations. The Project
S.A.F.E. Adolescent Evaluation Project was initiated in (the then )Region IV to provide
Substance Abuse Evaluations to adolescents who are suspected of substance abuse, but do not
meet the basic Project S.A.F.E. criteria. DCF Region IV Social Workers who believe that an
adolescent would benefit from a Project S.A.F.E. evaluation should complete the following
forms prior to contacting the North Central Region ARG:


Adolescent Screening Form
Project SAFE Referral Form
These two forms are then reviewed by the ARG, and approved if clinically appropriate. Once
approved, the ARG or designee will call the ABH Intake Coordinator at 1-800-272-0097, and
make the referral.
Comprehensive Evaluation:
The Comprehensive Evaluation Pilot Project began in March 2002, with the following
objectives:
 To develop and standardize a comprehensive bio-psycho-social evaluation for Project
S.A.F.E. clients;
 To collect comprehensive information about the clients served by Project S.A.F.E.;
 To provide a process for efficient and effective distribution of substance abuse evaluation
results.
There are ten (10) providers that are participating in the Comprehensive Evaluation Pilot Project.
The referral process for this pilot project is as follows:
1. Make an evaluation referral by calling the 1-800 Project S.A.F.E line
2. Once referred, the provider utilizing a specifically designed Bio-Psycho-social
Evaluation that has been standardized will evaluate the client.
3. The form itself is used to collect data and should be completed entirely by the
evaluating clinician.
4. Once it is completely filled out, the form is faxed to ABH within thirty (30) days of
the date of service for processing.
5. ABH enters all of the information into a database, and then distributes a data
processed form to the following:
 Referring DCF Social Worker;
 Treatment Provider;
 Regional Substance Abuse Specialist (if requested).
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Individual Therapy
Individual therapy consists of one to one therapy in duration of up to one hour, with a frequency
of no more than once weekly and no less than once per month. Treatment focuses on reducing
symptoms, improving function, maintaining abstinence and relapse prevention.
Group Therapy
Group therapy consists of therapy in duration up to one and a half hours, with a frequency of
once weekly. Treatment focuses on reducing symptoms, providing psycho-education, improving
functioning, relapse prevention and maintenance of abstinence. Groups should be limited to no
more than twelve (12) clients per group session.
Family Therapy
Family therapy consists of therapy sessions with a client and one or more individual(s) identified
by the client as family, with duration of up to one hour, a frequency of no more than once
weekly. Treatment focuses on building and maintaining supports for recovery, repairing
relationships, reducing symptoms, providing psycho-education and maintenance of abstinence.
Intensive Outpatient Therapy (IOP)
A non-residential service provided in a general hospital, private freestanding psychiatric hospital,
state operated facility or in a facility licensed by the Department of Public Health as a
“Psychiatric Outpatient Clinic for Adults”. IOP services provides each client with three to four
(3-4) hours per day, three to five (3-5) days per week of clinically intensive programming
based on an individualized treatment plan. Treatment focuses on reducing symptoms, improving
functioning, maintaining community connection and relapse prevention. As a client is preparing
for discharge, titration of IOP may occur, decreasing the frequency to less than three (3) times
per week. IOP must include one therapy session per day, inclusive of (at least) one individual
therapy session per week. Random drug screens can be completed on the same day that a patient
attends and are reimbursed separately.
Partial Hospitalization Program (PHP)
A non-residential service provided in a general hospital, private freestanding psychiatric hospital,
state operated facility or by a provider that is a non-profit entity that involves ambulatory
intensive psychiatric and/or substance abuse treatment services. PHP services are designed to
serve individuals with significant impairment resulting from substance abuse as well as cooccurring psychiatric disorders. These services target adults who have recently been discharged
from inpatient facilities, or whose admission to inpatient care may be prevented by treatment in
PHP program. PHP consists of therapeutic programming of a minimum of four (4) hours per
day, at least four (4) days per week, based on a comprehensive and coordinated individualized
treatment plan involving the use of multiple concurrent treatment services and modalities.
Treatment focuses on reducing symptoms, improving functioning, maintaining community
connection, and relapse prevention. As a client is preparing for discharge, titration of PHP may
occur, decreasing the frequency to less than four (4) times per week. PHP must include one
therapy session per day, inclusive of (at least) one individual therapy session per week. Random
drug screens can be completed on the same day that a patient attends and are reimbursed
separately.
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Urine Drug Screens
Urine drug screens are used to determine the recent use/abuse of substances. Random urine drug
screens are defined as two (2) urine drug screens per week for a period of six (6) weeks.
Random screens should not occur on the same day and time each week. In order for the screens
to be random, the client may be contacted by the treatment provider and asked to come in within
the next twenty- four (24) hours for a drug screen, provided it is not on a day when treatment
services are provided. Random drug screens can also be requested for a client who is not in
active treatment under the following circumstances:
 In response to a court ordered request or;
 Has had an evaluation within the past six (6) months.
Hair Testing
Hair testing is utilized to determine a three-month history of substance use/abuse history prior to
the hair test. Careful collection of samples by authorized treatment providers following
collection guidelines is necessary to ensure effective use of hair testing. Positive hair test results
can be further analyzed to determine if the client’s use/abuse of substances occurred within
30/60/90 days prior to collection. This multi-sectional testing can be performed on a positive
sample per request of the referring DCF Social Worker. A hair test may be requested for some of
the following reasons:
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Family reunification planning is expected to occur in the immediate future.
DCF or provider staff has reason to believe that client has attempted to alter the urine
drug screens or failed to keep scheduled appointments.
Central or Area Office has concerns about a particular high risk or high profile case.
DCF staff identifies cases in which domestic violence is connected with substance abuse.
The Court requires documentation of historical drug use during a 30/60/90 day period
DCF staff identifies abuse/neglect cases in which the primary caregivers are said to be in
recovery from substance abuse.
Treatment Levels of Care
In this section guidelines adapted from the ASAM Patient Placement Criteria for the Treatment
of Substance Related Disorders, Second Edition Revised (ASAM PPC-2R), published by the
American Society of Addiction Medicine ASAM in 2001 are used to define treatment levels of
care. Each level of care has general characteristics and criteria. Project S.A.F.E provides
reimbursement to providers for all of the outpatient levels of care:
 Outpatient Services – Level I SA1.1
Individual Counseling, Family Counseling, Group Counseling, Urine Screens, and
Hair test
 Intensive Outpatient Services – Level II, SA II.1
 Partial Hospitalization Program Services – Level II, SA II.5
In an effort to provide general guidelines, we have included a level of care (page 13-15) table in
this Preferred Practices document. It is intended as a guide for clinical practice rather than a set
of rules.
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Service Limitations and Exclusions
A. The following limitations shall apply to substance abuse services performed under
Project S.A.F.E
a. Covered services and procedures are limited to those listed in the Project S.A.F.E.
fee schedule
b. At the time of initial referral from the DCF Social Worker the following types of
visits can be authorized:
i. One (1) evaluation
ii. One (1) urine drug screen
iii. Twelve (12) random drug screens
iv. One (1) hair test
v. Undisclosed number of outpatient SA I.1 levels of care
c. Medication Management is not a reimbursable service under Project S.A.F.E.
B. Reimbursement for the following behavioral health services is excluded under Project
S.A.F.E
a. Psychiatric evaluation
b. Medication Management
c. Psychological Assessment
d. Services that Project S.A.F.E., DCF and DMHAS determine are not directly
related to the diagnosis and treatment of a behavioral health disorder or those that
do not reduce symptoms and/or psychological distress.
e. Services, consultation or information provided over the telephone
f. Services that Project S.A.F.E., DCF and DMHAS determine are primarily for
vocational or educational guidance or that is related solely to a specific
employment opportunity, work skill work setting and/or the development of an
academic skill.
g. Breathalyzer
h. Methadone Maintenance
C. Project S.A.F.E. shall not reimburse for inpatient or residential levels of care.
D. Project S.A.F.E. does not reimburse for psychiatric evaluation or medication
management.
E. Project S.A.F.E. does not reimburse for any required spend-down funding, and/or copayment requirements
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Level of Care Guide (Table I)
Level I: (SA I.1 & MH I.1) Outpatient
Level of Care Guide
Level of Care
Level I: (SA I.1 & MH I.1)
Outpatient
ASAM
Dimension
Description of general criteria
Dimension 1
Patient has no signs and symptoms of
withdrawal.
If any biomedical conditions are
present, they are sufficiently stable to
permit participation in outpatient
treatment.
Any symptoms of a co-occurring
disorder are generally stable, may
require some monitoring, and do not
interfere with the patient’s ability to
focus on addiction treatment issues.
Mental status does not preclude ability
to understand information, and
participate in treatment.
Patient is willing to participate and
cooperate with treatment,
acknowledges that he or she has a
substance–related problem and wants to
change. If having difficulty with the
above, the patient may need
monitoring.
Patient is able to achieve abstinence
and/or an awareness of a substance
related problem
The patient’s psychosocial environment
is sufficient to support treatment
feasibility.
Dimension 2
Dimension 3
Dimension 4
Dimension 5
Dimension 6
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Level of Care Guide (Table II)
Level II: (SA II.1 & MH II.1) Intensive Outpatient (IOP)
Level of Care Guide
(continued)
Level of Care
ASAM
Dimension
Description of general criteria
Level II: (SA II.1 & MH II.1)
Intensive Outpatient (IOP)
Dimension 1
Patient has no signs and symptoms of
withdrawal.
If any biomedical conditions are
present, they are sufficiently stable to
permit participation in outpatient
treatment.
Patient engages in abuse of family or
significant others, and requires
intensive outpatient treatment to reduce
the risk of further deterioration, or the
patient has a diagnosis requiring
intensive outpatient monitoring to
minimize distractions from recovery.
Patients meeting Dimension 3
description require dual diagnosis
treatment.
Efforts at outpatient level (SA I.1 or
MH I.1) have failed to promote
recovery, or although the patient is
willing to participate, their perspective
inhibits ability to make behavior
change with repeated structured
intervention.
The patient has been an active
participant at a less intensive level of
care, he or she is experiencing an
intensification of symptoms, and his or
her level of functioning is deteriorating.
The patient lacks social contacts so as
to jeopardized recovery and/or
continued exposure to school, work, or
living environment will render recovery
unlikely.
Dimension 2
Dimension 3
Dimension 4
Dimension 5
Dimension 6
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Level of Care Guide (Table III)
Level II: SAII.5 & MH II.5 Partial Hospital & SA Day/Evening
Level of Care Guide (continued)
Level of Care
ASAM
Dimension
Description of general criteria
Level II: (SA II.5 & MH II.5)
Partial Hospital & SA
Day/Evening
Dimension 1
Patient has no signs and symptoms of
withdrawal.
If any biomedical conditions are
present, they are sufficiently stable to
permit participation in outpatient
treatment, however they may provide
distraction from recovery efforts.
The patient’s mental status history is
characterized by a mild to moderate
psychiatric decompensation on
discontinuation of the drug(s) of abuse.
Patients meeting Dimension 3
description require dual diagnosis
treatment.
Efforts at another treatment level have
failed and structured programmatic
milieu interventions are not likely to
succeed at Level II.1, or, although the
patient is willing to participate, their
perspective and lack of impulse control
inhibits ability to make behavior
change with repeated structured
intervention.
The patient has been an active
participant at a less intensive level of
care, he or she is experiencing an
intensification of symptoms, and his or
her level of functioning is deteriorating;
or a lack of awareness of relapse
triggers creates is a high likelihood of
relapse.
The patient’s family members or
significant others who live with the
patient are not supportive of recovery
goals, and continued exposure to
school, work, or living environment
will render recovery unlikely.
Dimension 2
Dimension 3
Dimension 4
Dimension 5
Dimension 6
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Referral and Authorization Process
There are a variety of procedures in which each party of Project S.A.F.E. is required to follow.
In the following section, we will outline what we (ABH) will do, and what DCF and/or the
Provider are required to do, in order that our clients receive services in an efficient, professional,
and timely manner.
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Service Authorization and Referral Process for Covered Services
One of Project S.A.F.E.’s goals is to ensure that adults involved in the child welfare system have
priority access to drug screening, substance abuse evaluations and outpatient services. By
definition Priority Access means once contacted with an evaluation referral the provider will
offer an evaluation appointment within five (5) business days. If requests are urgent, the
provider should attempt to offer an appointment within twenty-four (24) hours. The following
section sets forth the general requirements for referrals and service authorization for service
types and levels of care.
1. Initial Referral An initial referral is the first time DCF Worker has called ABH Project
S.A.F.E. regarding an identified client to make a referral.
a. An initial referral must be made to ABH in order for an individual to be
considered a Project S.A.F.E. client.
b. The DCF Social Worker must obtain a release of information for ABH prior to
making the referral.
c. A referral will only be accepted from a DCF Social Worker or other DCF
designated staff (Supervisor, Area Resource Group, Central Office).
d. To make a referral the DCF Social Worker calls the ABH Project S.A.F.E. intake
line (1-800-272-0097).
e. The DCF worker will be asked a series of questions including which Provider
they would like the client to see.
f. The Project S.A.F.E. Intake Coordinator(s) will enter the information into the
database all information asked, creating a Project S.A.F.E. Client ID number and
electronic record. The electronic record will include demographic information,
substance use concern as identified by the DCF Social Worker and an initial
authorization for the service/services being requested.
g. The Project S.A.F.E. intake coordinator will then fax the referral (which also
serves as the authorization) to the Project S.A.F.E. Provider.
2. Evaluation: The DCF Social Worker requests an evaluation once the DCF substance
abuse screen (DCF form 2110) is completed and there is suspicion that the individuals’
ability to parent effectively is impaired as a result of substance use. To include a urine
drug screen as part of the evaluation the DCF Social Worker should also request one (1)
urine drug screen.
1. Prior to making the ABH Project S.A.F.E. referral, the DCF Social Worker
will obtain a release of information from the client for Advanced Behavioral
Health and the provider.
2. The DCF Social Worker calls the Intake Coordinators at 1-800-272-0097.
3. The DCF Social Worker will provide basic demographics, reason for referral
and any updated information.
4. Once the Telephonic referral is completed, the Project S.A.F.E. Intake
Coordinator will fax the client referral form and substance abuse screening
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form [Appendix A] to the Project S.A.F.E. Provider. This serves as an
authorization for the evaluation.
5. The DCF Social Worker should fax the release of information to the provider.
Providers will be unable to schedule an appointment without a signed release
of information.
6. The Provider should verify the client’s health insurance using the EDS. If the
client has insurance the Provider should submit a claim to both ABH Project
S.A.F.E. and the client’s health insurance carrier. ABH Project S.A.F.E. is the
payer of last resort.
7. The preferred location for conducting evaluations is at the Provider’s place of
business; in addition the provider is expected to conduct a chain of custody
(See glossary of terms) urine screen.
8. Upon completing the evaluation, results should be verbally communicated to
the DCF Social Worker within twenty-four hours (one business day).
9. A written clinical summary should follow this verbal communication within
five (5) business days. The summary should contain the following minimum
information:
 Demographic information
 Family composition and history
 Substance abuse history
 Trauma history
 Medical history and current medical status
 DSM IV TR Diagnostic formulation
 Drug screen results
10. Upon completion of the evaluation Providers are responsible for faxing the
following forms to Project S.A.F.E. 860-638-5302 claims department
a. Client Report Form [Appendix B]
b. Needs Assessment Form (for females only) [Appendix C]
c. TANF Eligibility Form [Appendix D]
d. OTR completed if the Provider is recommending IOP or PHP levels of
care.
11. The Provider must inform the DCF Social Worker within twenty- four hours
when a client fails to show for a drug screen and/or evaluation before
rescheduling. It should be decided jointly who will contact the client to
reschedule. If a client has a history of “no shows” with the assigned Project
S.A.F.E. Provider, while reasonable efforts should be made to provide priority
access, the Provider may apply their agency’s policy regarding rescheduling.
The appointment has to be rescheduled and the client seen within 45 days of
the date of the original referral date. If this does not occur the DCF Social
Worker has to make another referral by calling the Project S.A.F.E. Intake
Coordinators.
3. Outpatient 1.1 levels of care: There are three (3) basic Outpatient services, which falls
under 1.1 levels of care that are reimbursable within Project S.A.F.E. (individual
psychotherapy, group counseling, and family counseling).
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a. The DCF Social Worker will make a telephonic treatment referral by calling the
intake coordinator at the ABH Project S.A.F.E.1-800 272-0097
b. The DCF Social Worker will need to provide:
i. Release of Information
ii. Client Insurance Information
iii. Client Social Security Number
iv. Results of DCF Substance Abuse Screen
v. Basic Demographic Information
vi. Reason for Referral
c. The intake coordinator will enter the referral information into the Project S.A.F.E.
data system and fax the referral. This referral also serves as the authorization for
the treatment provider.
d. The authorizations will allow the provider to receive reimbursement for the
provision of individual, group and /or family/couple counseling treatment.
e. The treatment must begin within forty-five (45) days of the start date of the
referral. If the client does not attend treatment within the forty-five (45) days of
the start date of the referral, then the DCF Social Worker must make a new
treatment only referral. The Provider should notify the DCF Social Worker when
a referral lapses beyond the 45-day limit to request that the DCF Social Worker
call in a treatment only referral.
f. The Provider is to notify the DCF Social Worker if the client does not show for
their treatment appointment.
g. The Provider should regularly report to DCF the course of the client’s treatment.
4. IOP: IOP services provides each client with three to four (3-4) hours per day, three to
five (3-5) days per week of clinically intensive programming based on an individualized
treatment plan.
a. IOP services may be recommended based on a bio-psycho-social evaluation that
has been completed within six (6) months of the service request.
b. The Provider must complete an OTR to ABH via facsimile at 860-638-5302. The
OTR can be downloaded from the following web address: www.abhct.com (for
process see Appendix E).
c. Services will be authorized based on a Utilization Review process
d. Clinical staff at ABH will review all OTR information for clinical appropriateness
and provider compliance with submission criteria.
i. Submission criteria
1. The OTR should be completed in its entirety.
2. The OTR should be submitted prior to admission to the IOP level
of care.
3. The Provider should promptly respond to any inquires for
supporting clinical information.
e. ABH will help to educate treatment providers about clinically appropriate
treatment planning and decision-making processes regarding level of care, review
OTR within three (3) business days. An OTR will be processed with one of the
following four outcomes:
Rev. 11/07
19
i. Authorization – an authorization will be processed, entered into the ABH
system and fax authorization notification will be generated and forwarded
to the provider
ii. Request for Additional Information- the clinician submitting the OTR will
be contacted telephonically, with a request for additional information;
iii. Administrative Denial – a denial letter will be issued based on procedural
exceptions;
iv. Clinical Denial – a clinical denial will be issued based upon a review of
clinical information.
f. ABH will provide an appropriate appeal process for all adverse determinations.
5. PHP: PHP consists of therapeutic programming with a minimum of four (4) hours per
day, at least four (4) days per week, based on a comprehensive and coordinated
individualized treatment plan involving the use of multiple concurrent treatment services
and modalities.
a. PHP services may be recommended based on a bio-psycho-social evaluation that
has been completed within six (6) months.
b. The Provider must complete an OTR and fax to ABH at 860-638-5302. The OTR
can be downloaded from the following web address: www.abhct.com (for process
see Appendix E).
c. Services will be authorized based on a Utilization Review process
d. Clinical staff at ABH will review all OTR information for clinical appropriateness
and provider compliance with submission criteria.
i. Submission criteria
1. The OTR should be completed in its entirety.
2. The OTR should be submitted prior to admission to the IOP level
of care.
3. The Provider should promptly respond to any inquires for
supporting clinical information.
e. ABH will review the OTR within three (3) business days. An OTR will be
processed with one of the following four outcomes:
i. Authorization – an authorization will be processed, entered into the ABH
system and an authorization notification will be generated and forwarded
to the provider
ii. Request for Additional Information- the clinician submitting the OTR will
be contacted telephonically, with a request for additional information;
iii. Administrative Denial – a denial letter will be issued based on procedural
exceptions;
iv. Clinical Denial – a clinical denial will be issued based upon a review of
clinical information.
f. ABH will provide an appropriate appeal process for all adverse determinations.
6. Random Drug Screens: Random urine drug screens are defined as two (2) urine drug
screens per week for a period of six (6) weeks and should not occur on the same day and
time each week. Urine Screens can be requested for clients who are not in treatment if in
response to a court ordered request.
Rev. 11/07
20
a. The DCF Social Worker makes a telephonic referral. This referral results in an
authorization for services
b. ABH Project S.A.F.E. will authorize 12 random urine screens.
c. The screens can be initiated at any time during the next forty-five (45) days. Once
the random screens have begun they may continue for a period of no longer than
six (6) weeks.
d. The Provider is required to collect all urine samples using the chain of custody
protocol as indicated on the reverse side of the chain of custody form.
e. The Provider, to schedule a random screen, will contact the client asking the
client to come in within the next twenty-four (24) hours for a drug screen,
provided it is not on a day when treatment services are provided.
f. The Provider will verbally communicate all toxicology screen results to the DCF
Social Worker within forty-eight (48) hours. Written results should be faxed to
the DCF Social Worker within 24 hours of receipt of written correspondence from
the lab.
7. Extended Drug Screens (e.g. Opiate Search)
a. The DCF worker consults with the SAS to receive authorization for any extended
drug screens, once the standard screen has been completed with a positive result.
b. If a urine screen is positive for heroin an Extended Opiate Search can be
conducted by having the Substance Abuse Specialist or designee of the Substance
Abuse Division approve this test by calling the ABH Billing Coordinator at 860704-6144. An Extended Opiate Search can differentiate the positive opiate as
heroin, hydrocodone, hydromorphone, morphine and oxycodone.
c. Once this has been obtained the SAS must call the ABH Billing Coordinator at
860-704-6144 with client name, ABH number, and verification of approval from
the Substance Abuse Specialist.
d. The provider will then be contacted by the SAS or DCF social worker notifying of
approval.
e. The provider will then complete the LabCorp request.
f. When results of the extended drug screen are received, the results should be
communicated to DCF upon receipt.
g. When received, the Provider should forward the specific LabCorp Invoice to
ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-638-5302.
8. Hair Testing: Hair testing is utilized to determine the substance use/abuse history of a
client up to three (3) months prior to the sample collection. This ‘standard’ test will
indicate whether a client has used any of the following substances during that period:
 Cocaine
 Opiates
 PCP;
 Methamphetamine
 Marijuana/THC
Rev. 11/07
21
In addition, when a positive result is determined by the standard hair test results, a multisectional test can be performed per request of the referring DCF Social Worker.
b. The DCF Social Worker will discuss the necessity and request for approval with
the Substance Abuse Specialist and/ or supervisor or designee in the Substance
Abuse Division.
c. The DCF Social Worker then calls the ABH Intake Coordinator at 1-800-2720097 for the hair test referral and provides the following information:
i. Name of person authorizing the test (SAS or designee has to approve
before the referral is called into ABH Project S.A.F.E.)
ii. Name and ABH number of the client
d. ABH Project S.A.F.E. identifies the provider performing the test, enters an
authorization and faxes notification to that provider.
e. The Provider will complete a Standard Test Request Form (TRF-ST-004) and
complete a hair test.
f. The Provider should collect a sufficient quantity of hair (about 2 inches in length
and 50 strand of hair cut about ¼ inch from the scalp). If the client has short hair
more hairs will be need to meet the collection needs.
g. The hair testing facility will complete a 5-panel hair toxicology screen (Cocaine,
Methamphetamine, Opiates, PCP, Marijuana). Results will be reported within 2-6
business days.
h. If there are positive results reported from the Standard Hair Test Screen, the
Provider can call the testing facility (Psychmedics at 1-800-522-7424) to request a
complete sectional analysis. It is important to clarify that you are calling about an
ABH client and requesting the additional testing. Psychmedics will invoice. ABH
directly for additional testing.
Rev. 11/07
22
Referral and Authorization Process (CHART)
Type of Service/Level Information Needed
of Care
From DCF
Information Need
from the Provider
Information needed or
provided by ABH
Authorization
Requirements
Evaluation (up to 90
minutes)
Results and
recommendations
forwarded to DCF
within five (5)
business days.
Client Referral Form,
which serves as the
authorization for the
evaluation.
Basic demographic
information and
substance abuse
information from the
DCF worker.
Telephonic
call from DCF
Random screens are
included. An evaluation
has been conducted
within the last six (6)
months.
Outpatient
(Individual, Group,
Family/Couples)
Release of Information
from the client.
Telephonic referral to
ABH.
Telephonic referral if
treatment only referral
or if there has been a
45 day lapse from the
initial referral call
IOP
PHP
Urine Drug Screen
Telephonic referral
Extended Drug
Screens
SAS authorization
Hair Test
SAS authorization,
Court Order and/or
Program Supervisor
authorization
Rev. 11/07
Client Reporting
Form, TANF, and
Needs Assessment
for women.
Verify client’s
insurance, check for
existing referral
An OTR needs to be
submitted before
services rendered
An OTR needs to be
submitted before
services rendered
Random screens have
to be done within six
(6) weeks
Utilization Review of
OTR
There has to
be an
evaluation
that has been
completed
within the last
six (6)
months. An
open referral
must exist.
OTR faxed to
ABH directly.
Utilization Review of
OTR
OTR faxed to
ABH directly.
Will authorize 12 units
to be conducted within
six (6) weeks.
LabCorp invoice via
fax for
reimbursement
See Hair testing
procedure
Reimbursement for
pre-authorized test
Telephonic
referral by
DCF worker
needs to be
called in prior
to services
Telephonic
authorization
Set up a referral upon
telephonic referral
Telephonic
authorization
23
Reimbursement Protocol
There are a variety of procedures that each party involved in ABH Project S.A.F.E. is required to
follow. In the following section, we will outline what we (ABH) will do, and what DCF and/or the
Provider are required to do, in order that client services are reimbursed.
Rev. 11/07
24
Provider Credentialing
Project S.A.F.E. services will be provided by agencies licensed by the Department of Public Health
to provide outpatient substance abuse services and that have an agreement with ABH. Professionals
within an agency who hold one of the following qualifications will be eligible to conduct
evaluations:





Certified Alcohol and Drug Counselor (CADC)
Certified Alcohol Counselor (CAC)
Licensed Alcohol and Drug Counselor (LADC)
Masters or doctoral level clinician with at least two years of experience in the treatment of
substance abuse
Connecticut licensed Registered Nurse with at least two years of experience in the
treatment of substance abuse
Staff with backgrounds other than those listed above will be considered on a case-by-case basis and
approved by the ABH Project S.A.F.E. Program Manager or designee. All non-certified or nonlicensed evaluators must be supervised by a licensed masters or doctoral level clinician.
Reimbursement
Project S.A.F.E. provides reimbursement for all authorized evaluations, outpatient treatment
services, drug screens/hair tests, and court costs. ABH Project S.A.F.E. offers providers a web
based electronic system to submit claims electronically; ABH Project S.A.F.E. encourages
providers to make use of this system. ABH offers training twice annually on how to submit claims
using the electronic system. ABH Project S.A.F.E. will make itself available to providers for
assistance or individual trainings on an ad hoc basis.
ABH Project S.A.F.E. is the payer of last resort and as such clients are expected to use their
insurance plan when receiving Project S.A.F.E. services. Providers will be reimbursed the
difference between what the insurance company pays, and the approved ABH reimbursement rate.
Fee schedules are furnished to provider groups as part of the initial and annual contracting.
Reimbursement Procedures:
 Evaluation
 Treatment
 IOP and PHP
 Drug Screens
o Urine Screens
o Extended Drug Screens
o Hair Test
 Court Appearances
Rev. 11/07
25
Reimbursement for Evaluation
DCF
Responsibilities
Provider
Responsibilities
The DCF Social Worker will need to call ABH Project S.A.F.E. 1-800-2720097 to make an evaluation referral. The DCF Worker will need to provide the
following information:
 Release of Information
 Client’s Insurance Information
 Client’s Social Security Number
 Results of DCF Substance Abuse Screen
 Basic Demographic Information
It is important to remember that an evaluation referral includes a referral for
treatment if the treatment services begin within 45-days of the date of the
referral.
****************************************************************
The Evaluation provider needs to be aware of any existing referrals.
Appointments should be provided within the priority access guidelines, if the
Provider is unable to do so, they should notify ABH Project S.A.F.E.
The provider needs to contact the DCF Social Worker with verbal results of an
evaluation within 24 hours, and with written results within 5 days.
A referral will lapse if no service is provided within a forty-five (45) day limit.
To determine if the Referral has lapsed, the Provider will look on the Client
Referral Form [Appendix A] review the service(s) requested end date. The
evaluation needs to be conducted before this date; if not the Provider should
request that the DCF Social Worker call ABH Project S.A.F.E. to make a new
referral.
The Provider needs to complete the following information and submit to the
ABH claims department:
 Client Report Form [Appendix B]
 For women only the Needs Assessment Form [Appendix C]
 TANF Eligibility Screening Form [Appendix D]
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this time
frame will be denied reimbursement for “untimely filing”.
If there is a correction required on any submitted claim, the Provider has 90
days from the service date to correct the claim.
****************************************************************
ABH Project
S.A.F.E. Will
Rev. 11/07
ABH will fax the referral information to the Provider when a DCF Social
Worker makes an evaluation referral. This referral information serves as the
authorization. [Appendix A] ABH will maintain an electronic record of every
referral, which will allow reimbursement for an evaluation provided.
26
Reimbursement for Treatment
DCF
Responsibilities
Provider
Responsibilities
The DCF Social Worker will need to call ABH Project S.A.F.E. 1-800-272-0097 to
make a treatment only referral. The DCF Social Worker will need to provide the
following information:
 Release of Information
 Client’s Insurance Information
 Client’s Social Security Number
 Results of DCF Substance Abuse Screen
 Basic Demographic Information
It is important to remember that if treatment begins within 45 days of the
evaluation referral start date no treatment referral needs to be called in by the DCF
worker.
*******************************************************************
The Treatment provider needs to be aware of any existing referrals.
If the treatment services begin within 45 days of the start date of the evaluation
referral, the Provider can submit claims as described in the claims submission
portion of this document.
If a referral lapses because it is beyond the 45 day limit, the provider should
contact the DCF Social Worker and request that he or she call in a new referral.
The provider should communicate the course of client treatment by contacting the
DCF Social Worker regularly. Providers who create a treatment plan which
recommends IOP or PHP must complete an OTR (see following reimbursement
section).
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this time
frame will be denied reimbursement for “untimely filing”.
Providers should verify the client’s insurance and indicate this information in the
claims submission process. If a client does not have insurance a special exception
can be granted. See Special Exception procedure (page 29).
Treatment-only referrals can be made under the following circumstances:
 Treatment-only referrals following an acute care episode;
 Treatment-only referrals resulting from the need to transfer a client from
one provider to another;
 Treatment-only referral following a lapsed forty-five (45) day referral.
In every case it is required that an evaluation has been completed (within the
previous six (6) months) prior to the DCF Social Worker making a treatment-only
referral through contacting the Project S.A.F.E. Referral Hotline at ABH.
*****************************************************************
Rev. 11/07
27
ABH Project
S.A.F.E. Will
Rev. 11/07
ABH Project S.A.F.E. will fax the referral information to the Provider when a
DCF Social Worker makes the treatment referral. ABH Project S.A.F.E. will fax
the Client Referral Form with Treatment Only indicated in the service(s)
requested section. (Appendix B) ABH will maintain an electronic record of
every referral, which will allow reimbursement for treatment. A separate
referral for urine screens is not required under a treatment only referral. Chain of
custody random urine screens will be reimbursed by ABH under the treatment
only authorization called in by the DCF worker.
28
Reimbursement for IOP or PHP Levels of Care
DCF
Responsibilities
Provider
Responsibilities
Ensure that all necessary information is available to both the treatment
provider and ABH.
************************************************************
IOP and PHP levels of care are authorized based upon a process of
Utilization Review (UR). To engage in this process the Provider must
submit an Outpatient Treatment Request Form (OTR) [Appendix E].
The OTR form must be completely filled-out, with the necessary
demographic and clinical information prior to admission to the IOP or PHP
levels of care.
An OTR form needs to be completed prior to the expiration or completion
of services previously authorized. Any subsequent OTR forms should be
completed with new clinical information and an updated treatment plan.
The provider is required to respond promptly to any inquiries for supporting
clinical information.
Once a it has been determined that the client is no longer in need of IOP or
PHP services a Discharge Notification Form [Appendix F] needs to be
completed.
ABH Project
S.A.F.E. Will
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this
time frame will be denied reimbursement for “untimely filing”. IOP and
PHP services can also be denied if the client does not meet clinical criteria.
*************************************************************
Help educate treatment providers about clinically appropriate treatment
planning, and decision-making processes regarding level of care decisions
as requested.
Receive and process Outpatient Treatment Requests (OTR) for IOP and
PHP levels of care through Utilization Review. In order to assure that the
patients who require IOP and PHP levels of care, these services are
authorized based upon a process of Utilization Review (UR). While no
effort is being made to restrict access to these levels of care, the goal of UR
ensuring that limited treatment funding provides treatment for those clients
with clinically appropriate need.
Provide a three-day turnaround time on authorization decisions, with access
to urgent authorizations when clinically necessary.
Provide an appropriate appeal process for all adverse determinations. (See
Appeals Process page)
Maintain a copy of the OTR for download at the following web address:
https://www.abhct.com
Rev. 11/07
29
Reimbursement for Hair Testing
DCF
Responsibilities
Provider
Responsibilities
Hair test can be requested by the DCF Social Worker to determine if a
client has abused a substance over the past 90 days. Hair testing is useful
for obtaining historical use within a 90-day period. To request a hair test
and receive reimbursement the DCF Social Worker will contact the
Substance Abuse Specialist in their respective offices for approval. Once
this approval has been granted DCF should contact ABH Project S.A.F.E.
************************************************************
The provider is required to collect a sufficient sample for a hair test in
accordance with standards for hair testing as specified in the training. The
provider then submits the sample, with a request for a standard screen to
Psychemedics.
If the results are positive the provider can request a multi-sectional testing
of the positive result, by calling Psychemedics at their toll-free number and
requesting a multi-sectional be completed. This multi-sectional does not
require the client to return to the office and will not be reimbursed by ABH.
Results should be discussed with the DCF Social Worker through
telephone contact as soon as possible.
ABH Project
S.A.F.E. Will
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this
time frame will be denied reimbursement for “untimely filing”.
*************************************************************
ABH will serve as the coordinator of Hair testing requests, and as the
conduit for information between Psychemedics and other parties involved.
ABH will help expedite procedures whenever possible, and will provide a
forum for annual training for any provider who is interested.
ABH will ensure that Psychemedics is meeting the criteria for timely
reporting of results, through a monitoring program.
ABH will provide reimbursement to providers, which includes an
administrative fee related to collection and submission of the sample to
LabCorp, and the actual cost that LabCorp invoices the provider for
completion of urinalysis.
Rev. 11/07
30
Reimbursement for Random Urine Drug Screens Only
DCF
Responsibilities
The DCF Social Worker will contact ABH with a request for random drug
screens. Project S.A.F.E. allows a Provider to perform random urine drug
screens for clients who are not engaged in treatment, but require
monitoring.
Random urine toxicology screens cannot be implemented in the absence of
a completed evaluation in the past six months, or a court order, or a client
being in active treatment.
Provider
Responsibilities
Providers are required to follow the to chain of custody protocol for
collecting and forwarding urine specimens.
Providers are required to report to the DCF worker the results of all
negative drug screens within forty-eight (48) hours and all positive drug
screens within seventy-two (72) hours. Written results should be faxed to
the DCF Social Worker upon receipt of the results. If there is a positive
Opiate result, the DCF Social Worker can request an extended opiate
search. (See below for instruction:)
Extended Opiate Search has to be approved by the Substance Abuse
Specialist in the respective DCF area office. Once this has been obtained
DCF needs to call the ABH Billing Coordinator at 860-704-6144 with
client name, ABH number, and verification of approval from the Substance
Abuse Specialist. The Provider should then send in the Labcorp Invoice to
ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-6385302. (see detail in Reimbursement for Extended Opiate Search )
ABH Project S.A.F.E. will authorize 12 random drug screens over a sixweek period. The Provider at the end of this period shall notify the DCF
Social Worker to call ABH Project S.A.F.E. for subsequent referrals for
urine screens if applicable.
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this
time frame will be denied reimbursement for “untimely filing”.
*************************************************************
ABH Project
S.A.F.E. Will
Rev. 11/07
ABH will authorize a total of twelve (12) random drug screens over a sixweek period. ABH Project S.A.F.E. will receive referrals for this service
via their toll-free Project S.A.F.E. intake line.
31
Reimbursement for Extended Drug Screens (extended opiate search)
DCF
Responsibilities
Provider
Responsibilities
The DCF Social Worker will review the case with the Substance Abuse
Specialist (SAS) in their Area Office. The SAS will contact the Project
SAFE Billing Coordinator to authorize an extended drug screen.
************************************************************
Providers are required to follow the to chain of custody protocol for
collecting and forwarding urine specimens.
Providers are required to report to the DCF worker the results of all
negative drug screens within forty-eight (48) hours and all positive drug
screens within seventy-two (72) hours. Written results should be faxed to
the DCF Social Worker upon receipt of the results. If there is a positive
Opiate result, the DCF Social Worker can request an extended opiate
search. (See below for instruction:)
Extended Opiate Search has to be approved by the Substance Abuse
Specialist in the respective DCF area office. Once this has been obtained
DCF needs to call the ABH Billing Coordinator at 860-704-6144 with
client name, ABH number, and verification of approval from the Substance
Abuse Specialist. The Provider should then send in the LabCorp Invoice to
ABH via mail 213 Court Street, Middletown, CT 06457 or fax to 860-6385302. (see detail in Reimbursement for Extended Opiate Search )
ABH Project S.A.F.E. will authorize 12 random drug screens over a sixweek period. The Provider at the end of this period shall notify the DCF
Social Worker to call ABH Project S.A.F.E. for subsequent referrals for
urine screens if applicable.
The Provider must submit claims for reimbursement no more than 30 days
following the date the service was provided. Claims submitted beyond this
time frame will be denied reimbursement for “untimely filing”.
*************************************************************
ABH Project
S.A.F.E. Will
Rev. 11/07
ABH will authorize a total of twelve (12) random drug screens over a sixweek period. ABH Project S.A.F.E. will receive referrals for this service
via their toll-free Project S.A.F.E. intake line.
32
Requests for Court Cost Reimbursement
DCF
Responsibilities
Provider
Responsibilities
Project S.A.F.E. providers on occasion are subpoenaed to testify in court
regarding DCF cases. In order to support the benefit of such testimony, DCF has
agreed to reimburse providers for their time as related to court testimony through
Project S.A.F.E.
******************************************************************
When a provider receives a subpoena to give testimony in court on a Project
S.A.F.E. case, the provider may request to be placed “on call” by contacting the
Assistant Attorney General (AAG) at the telephone number listed on the
subpoena. If the provider is unable to reach the AAG, the provider may contact
the Attorney General’s Office in Hartford at 860-566-3696 and request to be
placed “on call” for the specific case.
If the provider goes to court on a Project S.A.F.E. case, the provider may bill
ABH based on the time spent in the courtroom, whether or not the provider
actually testified in the case.
To be reimbursed, the provider will type a brief letter to the ABH Project
S.A.F.E. Manager identifying the client by name and ABH number, the date of
the court appearance, and the name of the clinician with the appropriate rate and
final figure (please refer to the fee schedule). Whenever possible the letter should
be co-signed by the Executive Director of the agency.
****************************************************************
ABH Project
S.A.F.E. Will
Rev. 11/07
ABH will provide reimbursement to providers, for time spent in court.
ABH will remit that reimbursement upon receipt of appropriate written documentation.
33
Special Exceptions
ABH is the payer of last resort; the term ‘payer of last resort’ indicates that the Project S.A.F.E.
funds are used to reimburse providers on a fee-for-service basis when there is no other source of
reimbursement available. DCF and DMHAS recognize that there are circumstances under which a
client may not be able to access services under their current payer source or under the structure or
function of payer of last resort hence there may be exceptions granted. Exceptions are granted only
for the circumstances indicated below:







ABH provider does not participate in the client’s insurance plan and referring the client to
another ABH provider is not an option.
The client has no reliable transportation to the in-network provider and the client has to be
referred to an out of network provider
Client has insurance but does not want their employer to know they are in treatment
Insurance company/entitlement does not provide the needed level of care
After treatment has begun, client’s insurance plan changes
Client may go from having no insurance to having insurance, with the provider being out-ofnetwork
Out-of-network provider offers daycare/babysitting and/or transportation services
The intention of granting special exceptions for the aforementioned circumstances is to ensure that
services will not be disrupted. The special exceptions system was established to make concessions
for special circumstances when appropriate and to track the frequency of such conditions.
To obtain special exception the following steps need to followed:
1. A Special Exception Form [Appendix G] needs to be completed in its entirety.
2. The form should be complete on or before the date of service. ABH will only back date up
to five business days.
3. The form is then faxed to ABH at 860-638-5302.
All information must be provided for the exception to be granted and services reimbursed.
Exceptions other than those listed here should be directed to the Project S.A.F.E. Program Manager
or designee. Every effort will be made to address any and all unique circumstances in an efficient
manner.
Rev. 11/07
34
V. Claims Process
There are a variety of procedures that each party involved in Project S.A.F.E. is required to follow.
In the following section, we will outline steps to assist in claim submission.
Rev. 11/07
35
Overview
The claim submission process is the system in which ABH Project S.A.F.E. will reimburse network
providers for services rendered to clients. ABH utilizes a web based claims submission system. For
services to be reimbursed an authorization needs to exist in the ABH Project S.A.F.E. data system
(please see referral and authorization section). Once a referral has been made by DCF, Providers
must submit claims for reimbursement no more than 30 days following the date the service was
provided. Claims submitted beyond this time frame will be denied reimbursement for “untimely
filing”. In using the web based claims submission system the provider will need to have a password
to access the system.
Each agency will follow their internal procedure for claims submission.
Providers who have submitted a claim electronically in the form of a response code “9”, or who
have submitted a claim manually, have a maximum of 90 days from the service date to correct the
claim. Should there be a compelling reason why the claims submission may be delayed, a call
should be made in advance to the ABH Claims Coordinator (860-704-6144) to explain the reason
(staff shortage, vacation schedules, etc.)
In the web based claims system there will be six tabs:
Six Tab Web Base Claim System
Rev. 11/07
36
1.
2.
3.
4.
Problem/Unpaid- denials
To be paid –authorized payment has been approved payment to be issued by next closing
New Claim – claim needs to be submitted
Reports – tells who has been paid, denied or is pending payment for a given period of time.
This is based on the ABH closing date
5. Change Login – change your log in information
6. Logoff – to exit the system
To complete the electronic claims process the provider will need insurance information, TANF
eligibility form and basic demographic information. All fields should be completed [See Appendix
H]
All dollar values will pre-populate in accordance with provider rates. Provider rates are updated
each fiscal year.
Claims may also be submitted manually. A form can be requested from the ABH Claims
Coordinator at 860-704-6144.
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Complaints, Grievances, and Appeals
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Utilization Review Process
Before authorizing any services for Project S.A.F.E. clients ABH Utilization Review staff must
ascertain whether the client’s symptoms meet Service Necessity Criteria for the requested service.
The Utilization Review staff may use the ABH Medical Director or his/her designee to assist in
making that determination.
In order to make a determination that the requested service(s) meet the Service Necessity Criteria,
the service must meet all the following criteria:
 The service is appropriate for the symptoms, diagnosis and treatment of a particular disease
or condition that is defined under the DSM IV-TR or its successor.
 The service is provided in accordance with generally accepted standards of mental health
and/or substance abuse professional practice and bio-psycho-social approach to
rehabilitation.
 The type, level, and length of treatment services are needed to provide safe, adequate and
appropriate care, and are intended to improve the individual’s condition. Treatment geared
toward simply maintaining the individual’s current level of functioning is appropriate only
when, without such treatment, the individual would be likely to suffer a relapse or
deterioration of health status. Service Necessity Criteria does not include “custodial care”.
All clinical denials must be based on a review made by a Connecticut licensed clinical reviewer. If
during the normal course of the review, a provider decides to withdraw the request for additional
services, the case does not have to be subject to clinical review.
If the Utilization Review staff determines that Service Necessity Criteria has not been met, the
provider will be notified via certified mail of the decision.
Appeals:
There are two types of appeals that may be lodged regarding denial of service by ABH Project
S.A.F.E.: clinical appeals and administrative appeals.
Clinical appeals: A provider, his/her authorized representative or designee may appeal a decision to
deny, reduce or terminate a behavioral health service. The appeals process is as follows:
 Upon receipt of the denial, an appeal may be initiated by providing additional justification of
the need for service. This appeal must be submitted to ABH no later than seven calendar
days after receipt of the denial decision.
 The Provider or his/her authorized representative will be sent notice of the decision on the
appeal no later than four business hours after receipt of information required rendering a
decision.
 If dissatisfied with the first level appeal decision, a second level appeal must be submitted to
ABH no later than seven calendar days after the first level appeal denial.
 The Provider or his/her authorized representative will be sent notice of the decision on the
second appeal no later than two business days after receipt by ABH Project S.A.F.E. of
information required to render a decision.
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

If dissatisfied with the second level appeal decision, a third level appeal must be submitted
directly to DMHAS no later than seven calendar days after the second level denial.
A third level appeal will not be considered if the first or second level appeal is still being
reviewed within the established time frames.
Administrative Appeals: A provider may appeal a decision by ABH that is based on noncompliance with administrative procedures. The appeals process is as follows:
 Within seven (7) calendar days of the denial from ABH, the provider or his/her authorized
representative may initiate the administrative appeals process by providing additional
information or by demonstrating “good cause”.
 The provider will be sent notice of the decision within seven business days following receipt
of the appeal by ABH. The notification will include the principal reason (s) for the decision
and instructions for requesting a further appeal, if applicable.
 If dissatisfied with the first level decision, the provider or his/her authorized representative
may submit a second level appeal directly to DMHAS no later than seven days after the
denial of the first appeal. The appeal must be accompanied by information necessary and
sufficient to render a decision.
For first level appeals send correspondence to:
Advanced Behavioral Health
Project S.A.F.E.
213 Court Street
Middletown, CT 06457
For second level appeals complaints or grievances, send correspondence to:
DMHAS Department of Mental Health and Addiction Services
Karen Orhenberger
410 Capital Ave., MS#14HCO
P.O. Box 341431
Hartford, CT 06134.
Complaints and Grievances:
A Project S.A.F.E. client may utilize the Providers established grievance procedure to seek
resolution of complaints and grievances concerning the quality or level of services provided.
Grievances are defined as a complaint against a service provider in matters other than the denial,
reduction or termination of services.
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Appendices
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Appendix A
CLIENT REFERRAL FORM (page 1)
Advanced Behavioral Health, Inc.
Middlesex Corporate Center
213 Court Street, 10th Floor
Middletown, Connecticut 06457
Social Worker
Name . . . .
City . . . . .
Phone . . . .
FAX . . . . . .
Unit . . . . .
Supervisor
Date:
Time:
Page:
Provider
Name . .
Phone . .
Address
City . . .
Contact .
Region .
Client Information
ABH ID #. .
Name . . . .
Address . . .
City . . . . . .
Insurance
Payor . . . .
Health Plan
Gender . .
Race . . . .
Soc Sec # .
Language
Link # . . . .
Date of
Phone . . . .
Substance Abuse Treatment Code .
Suspected Substance(s) Use:
Reason(s) for Suspecting:
Service(s) Requested:
# Units
Begin Date End Date
Reason for referral
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CLIENT REFERRAL FORM (page 2)
Advanced Behavioral Health, Inc.
Middlesex Corporate Center
213 Court Street, 10th Floor
Middletown, Connecticut 06457
Date:
Time:
Page:
Client ID . .
Name . . . .
Substance Abuse Screening / Information Form
1. Client appeared to be under the influence of drugs and/or alcohol.
2. Client showed physical symptoms of trembling, sweating, stomach cramps, nervousness.
3. Drug paraphernalia was present in the home, i.e., pipes, charred spoons, foils, blunts, etc.
4. Evidence of alcohol was present in the home, i.e., excessive number of visible bottles/cans
whether empty or not.
5. There was a report of a positive drug screen at birth
list drugs
 Mother  Child
6. There was an allegation of substance abuse in CPS Report.
7. The child(ren) reports substance abuse in the home.
8. The client has been in substance abuse treatment.
9. The client has used the following in the last twelve
 Marijuana/Hashis
 Heroin/Opiates  Cocaine/Crack  Other Drugs
10. Client shared that s/he has experienced negative consequences from the misuse of alcohol,
i.e.,
 DWI/DUI  Domestic Fights  Job Loss  Arrests
 Other:
11. Client shared s/he has experienced trouble with the law due to the use of alcohol or other
drugs, i.e.,
 DWI/DUI  Domestic Violence  Drug Possession
 Other:
12. There are adults who may be using drugs and/or misusing alcohol who have regular
contact with the client's child(ren).
13. The client acknowledged medical complications due to the use of substances.
14. Other Comments
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Appendix B
CLIENT REPORT FORM
ABH Contact:
Referral Date/Time:
Ref #:
ADVANCED BEHAVIORAL HEALTH, INC.
Middlesex Corporate Center, 10th Floor, Middletown, CT 06457
Phone: 860.638.5309 Fax: 860.704.6179
PROJECT SAFE
DCF Substance Abuse Services for Primary Care Givers
To:____________________________ and __________________________________
DCF SOCIAL WORKER
ABH INTAKE WORKER
DATE:____________ CLIENT NAME:_____________________________________
ABH CLIENT ID #______________
The above client received: (Check all that apply)
DRUG SCREEN:____________
EVALUATION:______________
TREATMENT RECOMMENDED: CHECK ONE
START DATE FOR BELOW TX:_____________
_____ NO TREATMENT RECOMMENDED
_____ INDIVIDUAL THERAPY
_____ GROUP THERAPY
_____ FAMILY/COUPLE THERAPY
_____ INTENSIVE OUTPATIENT
_____ PHP
_____ EARLY INTERVENTION
_____ METHADONE (Not funded by DCF contract)
_____ INPATIENT DETOX (Not funded by DCF contract)
_____ AMBULATORY DETOX (Not funded by DCF contract)
_____ RESIDENTIAL SERVICES (Check below; not funded by DCF Contract)
With Children________
Without Children________
Clinician Name: _________________________________________ Date:___________
(Please Print/Required field)
SIGNATURE_____________________________________________
Name of Provider
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__________________________________
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Appendix C
Needs Assessment Form
ADVANCED BEHAVIORAL HEALTH, INC.
Residential Services for Substance Abusing Women and Their Children
Client Name:
ABH #:
Date of Evaluation:
Evaluator:
Provider:
_____Yes _____No Is this client clinically most appropriate for residential treatment?
(If No, Stop Here, if Yes Continue.)
Please complete the following on all clients for whom residential is assessed as the most clinically
appropriate level of care. (Regardless of whether a referral for that level of care is actually made.)
_____Yes _____No
Client accepted recommendation for residential treatment.
If No, why not? (childcare, work, etc.) ___________________
_____Yes _____No
Bed was available.
Name of Residential Program__________________________
If not admitted to residential treatment, did client accept referral to alternative level of care?
_____Yes _____No
If Yes, specify level of care_____________________________________
DCF-Needs Assessment Form March 2003
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Appendix D
TANF ELIGIBILITY SCREENING FORM
Client Name:
ABH ID #:
1:
Does the case involve a foster parent or a parent with a
Write Yes or No
child that has been removed from the home?
If the answer to question 1 is yes, you do not need to answer questions 2, 3 and 4. The family is
automatically TANF eligible and the worker would need to select the code 01 (TANF eligible) in
the appropriate section of the ABH-DCF Weekly Activity Report (i.e. the claims forms). If the
answer is no, proceed to 2.
2:
Is the client a parent or caretaker relative with a minor
Write Yes or No
child living in the home?
If the answer to question 2 is no, you do not need to answer questions 3 or 4. The client is not
TANF eligible and the worker would need to select code 02 (not TANF eligible) in the appropriate
section of the ABH-DCF Weekly Activity report. If the answer is yes, proceed to 3.
3:
Is the client currently eligible for Medicaid, HUSKY,
Write Yes or No
Food
Stamps, TFA cash assistance or child care assistance?
If the answer to question 3 is yes, you do not need to answer question 4. The client is automatically
TANF eligible and the worker should select code 01 (TANF eligible) in the appropriate section of
the ABH-DCF Weekly Activity Report. If the answer is no, or the worker is unable to determine if
the client receives any of these benefits, then the worker should proceed with question 4.
4:
Number of parents,
75% of
75% of
Is family income below the
Children, and relatives
State
State
75% SMI for that family’s
living in the home
Median
Median
size? Write Yes, No, or
Income
Income
Unable to Determine
(Annual)
(Monthly)
2
$38,522
$3,211
3
$47,586
$3,966
4
$56,651
$4,721
5
$65,715
$5,477
6
$74,779
$6,232
7
$76,478
$6,374
8
$78,178
$6,515
9
$79,877
$6,657
10 and above
$81,577
$6,799
If the answer to the question is yes, then the worker should select code 01 (TANF eligible) in the
appropriate section of the ABH-DCF Weekly Activity Report. If the answer is no, then the worker
should select code 02 (not TANF eligible). If the answer is unable to determine, then the worker
should select code 03 (unable to determine).
TANF Eligibility Status (please circle the appropriate answer):
Yes
No
Unable to Determine
Date:_______________________________ProviderName:_______________________________
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Appendix E: Outpatient Treatment Request Downloading Procedure
Procedure for Downloading OTR Form
Once you access the ABH website you will see this screen.
Move the cursor to Resources tab. A drop down list will appear.
Move the cursor to ABH Downloads
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Outpatient Treatment Request Downloading Procedure (page 2)
Double Click ABH Downloads, this will the following screen.
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Outpatient Treatment Request Downloading Procedure (page 3)
Move the cursor to ABH Project SAFE
Highlight Project SAFE Outpatient Treatment Request Form
Double click
This should open the form.
It is recommended that you Save As and rename the document to a folder on your computer.
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Appendix F: Discharge Notification Form
Form Completed By:
Telephone #:____________________ Date:
Project SAFE
Discharge Notification Form*
Provider Name:
Provider Service Location:
Admission Date:
Discharge Date:
(2)
Client Name:
Client ABH ID#:
Client’s Date of Birth:
DIAGNOSIS – AXIS I:
(1)
DISCHARGE TYPE
Regular (Completed Treatment)
Refused Care (Refused Treatment Referrals)
AMA (Against Medical or Clinical
No Care (No Discharge Referrals/Plan Made)
Advice)
Transfer (transfer to higher level of care, or same level of care at a different location)
Noncompliance (Did not follow treatment recommendations)
Administrative (Violation of program rules)
AWOL (Left inpatient level of care without permission/staff
knowledge)
Other (Please describe):
Did the client complete treatment?
DISCHARGE PLAN
Provider Name:
Service/Level of Care:
Date of 1st
Appointment:
Discharge
Medications:
Yes
No
Number of Sessions Attended (if known) _________________
If there was no Plan,
please explain :
Living Arrangements
at Discharge
Homeless
DCF Involvement:
Yes
Dependent Living (Residential, Halfway house, Supportive Housing, Shelter)
Independent
No (if yes please complete the questions below):
DCF Case Status: Closed case
DCF Notified of Discharge Plan
Active Case
No (If yes, the date of notification, _______/_________/________)
mm
dd
yyyy
Name of DCF Worker: _______________________________________________________________________
Form Completed By:
Yes
Telephone #:____________________ Date:
*Discharge Notifications may be submitted by fax to: Advanced Behavioral Health, Inc. at (860) 638-5302
Project SAFE requires Discharge Notification for all authorized PHP or IOP services.
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Appendix G
Special Exception
ABH Project SAFE
Special Exception (formerly Regional Administrator’s Approval)
Date of Request:
Provider Name:
Person Requesting Exception:
Client Name:
Client ABH#:
Client DOB:
Client SSN:
-
-
Client’s Insurance Provider:
Reason for Exception:
Provider does not participate in client’s insurance plan
Insurance out of Network
Client refuses to use insurance
Insurance change to out of network
In-network service does not have childcare
Services not covered by client’s insurance plan
No transportation to in-network provider
Type of Treatment Requested:
Individual
# of sessions:
Anticipated Start date:
Anticipated End date:
Group
# of sessions:
Anticipated Start date:
Anticipated End date:
Family
# of sessions:
Anticipated Start date:
Anticipated End date:
Random Urine Drug Screen
# of sessions:
Anticipated Start date:
Anticipated End date:
Clinician Signature:
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FAQ for Project SAFE Special Exceptions
(Formerly Regional Administrator’s Approval)
1. What is a special exception?
The special exception was formerly known as the Regional Administrator’s Approval. It is a means which
providers who are unable to access client’s insurance can be reimbursed for services. Special exceptions are
granted under the following circumstances:
 Services rendered are not covered by the client’s insurance
 The Provider is out of the client’s insurance network
 The client refuses to use his/her insurance
 The in network provider does not have childcare or transportation available to the client.
No special exception needs to be completed for evaluation services. This only applies to outpatient services
including group, individual, family and urine drug screens.
2. When should I fill out a special exception?
A special exception form should be completed after insurance has been verified and the client meets the above
criteria. Project SAFE is the payer of last resort; as such the Provider is expected to bill the client’s primary
insurance first. If the client refuses to use his/ her insurance this would then require a special exception for
continued treatment of group, individual and/or family. No special exception is needed for the evaluation
service.
A special exception form should be completed prior to the service start date or the first date of service. Special
exceptions submitted more than five calendar days after the date of service will be denied for untimely
submission.
3. Who needs to complete the special exception?
The special exception form can be completed by any staff at your agency familiar with the client this includes
administrative assistants, case managers, clinicians or billing staff. All the information needs to be included
(client name, ABH#, client DOB, Type of treatment, number of sessions being requested, start and end dates of
treatment).
4. What services can be requested with the special exception?
Only outpatient services can be requested by special exception. These include: group, individual, family and
urine drug screen. If you are requesting group, individual or family urine drug screens are included in this
treatment modality. Urine drug screens can be requested but need a prior authorization from the DCF worker.
5. If a client comes in for an evaluation and has a previous evaluation at another facility within the
past year will ABH reimburse for the Project SAFE evaluation if the client’s insurance will not?
Project SAFE will cover the substance abuse evaluation if the client’s insurance will not cover the service. A
claim should be submitted for the evaluation with a note indicating that the client’s insurance will not cover
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services. This does not require a special exception and should follow the traditional claims process for
evaluations.
6. If there is a denial from SAGA for outpatient services, will Project SAFE reimburse under a
special exception?
Yes, Project SAFE would reimburse under a special exception. This would be viewed, as the client’s insurance
not covering services. This however only applies to outpatient services including individual, group and family.
7. If a client is on spend down and does not have the money to cover services, will Project SAFE
reimburse for services rendered?
Spend down is based on the State Medical Assistance program (Medicaid) operated by DSS. There are certain
qualifications that an individual must meet to be eligible for Medicaid. Spend down is used when a person is not
eligible based on excess income. In some cases a person can qualify if there income is over limit. This process
is spend down and lets the person reduce the excess income to bring them within eligibility for Medicaid.
The provider should verify that the client is on SAGA, but indicate on the Special Exception form that the client
refuses to use insurance due to spend down.
8. If a client on private commercial insurance reports that they cannot afford their co-pay will
Project SAFE reimburse the provider?
There is a precedent in place regarding reimburse of any co-pay. DCF and DMHAS feel that paying a
Medicaid co-pay goes against the spirit of Medicaid regulation likewise with commercial co pay reimbursement
of a client’s copy would subverts the payer’s co- pay policy.
9. If the client is in IOP or PHP, but is also receiving other treatment i.e. domestic violence, anger
management, and the insurance is paying for IOP or PHP and will not cover the other treatment
will Project SAFE reimburse for the other treatment service?
Project SAFE will reimburse for treatment not covered by the insurance, if the client has been provided an
Project SAFE evaluation and authorization for services have been called in by the DCF worker or treatment
begins with 45 days of the initial referral.
10. If the clinician providing the clinical services is not credentialed with the client’s insurance
company, but the Provider agency is in the network will Project SAFE reimburse under a special
exception?
Yes, this is listed as one of the reasons for special exception and will be reimbursed by Project SAFE.
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Appendix H:
Screen Shot of Web-Based Claims System
User Name : Trainning, ABH
Service Date:
12/28/2005
ABH ID:
42578
Service Type:
Evaluation
Client Name, DOB, and/or Social Security Number was corrected. Please change applicable ABH Referral information
First Name:
SSN:
Payor:
Health Plan:
None
TANF:
ABH Amount:
$
Expected Amount:
$
Balance Due:
$
Note/Message:
Client Refused to disclose insurance information
Payor source information corrected - Verification of benefits performed
Client Report Form (complete only on Evaluation Claims)
Evaluator Name:
Treatment Recommendations (check all that apply)
No Treatment Recommended
Services Funded by DCF
Individual Therapy
Methadone Maintenance
Group Therapy
Family/Couple Therapy
Intensive Outpatient
Early Intervention/Group
Day/Evening Treatment/PHP
Services NOT Funded by DCF
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Residential Services with Children
Inpatient Substance Abuse
Residential Services without Children
Psychiatric Services
Residential Services - Unspecified
Submit
General Help: Support@ABHCT.com
Web-Based Claims System Help: EbillingSupport@ABHCT.com
©Copyright Advanced Behavioral Health, Inc.
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