Rehabilitative Services for Persons with Mental Illness
Section II
SECTION II - REHABILITATIVE SERVICES FOR PERSONS WITH
MENTAL ILLNESS (RSPMI)
CONTENTS
200.000
201.000
202.000
202.100
202.200
210.000
211.000
212.000
213.000
213.010
213.100
214.000
215.000
216.000
217.000
217.010
217.020
217.100
217.111
217.112
217.113
218.000
218.001
218.100
218.101
219.000
219.100
219.110
219.130
219.140
219.141
220.000
220.100
220.200
221.000
221.100
221.110
221.200
221.210
221.220
221.230
221.240
221.250
221.260
222.000
223.000
224.000
224.100
224.200
REHABILITATIVE SERVICES FOR PERSONS WITH MENTAL ILLNESS (RSPMI)
GENERAL INFORMATION
Introduction
Arkansas Medicaid Participation Requirements for RSPMI
Certification Requirements by the Division of Behavioral Health Services (DBHS)
Providers with Multiple Sites
PROGRAM COVERAGE
Coverage of Services
Quality Assurance
Staff Requirements
Psychology Interns
Mental Health Paraprofessional Training
Facility Requirements
Non-Refusal Requirement
Scope
RSPMI Program Entry
Follow-up to Missed Beneficiary Appointments and Discharges
Reserved
Primary Care Physician (PCP) Referral
Procedure Codes Not Requiring PCP Referral for Beneficiaries Under Age 21
Medicaid Eligible at the Time the Service is Provided
Medicaid Ineligible at the Time the Service is Provided
Master Treatment Plan
Participation of Families and Children in the Development of the Treatment Plan for
Children Under Age 21
Periodic Treatment Plan Review
Participation of Families and Children in the Periodic Review of the Treatment Plan
for Children Under Age 21
Covered Services
Outpatient Services
Daily Limit of Beneficiary Services
Routine Venipuncture for Collection of Specimen
Telemedicine (Interactive Electronic Transactions) RSPMI Services
Services Available to Residents of Long Term Care Facilities
Inpatient Hospital Services
Hospital Visits
Inpatient Hospital Services Benefit Limit
Medicaid Utilization Management Program (MUMP)
MUMP Applicability
MUMP Exemptions
MUMP Procedures
Direct Admissions
Transfer Admissions
Retroactive Eligibility
Third Party and Medicare Primary Claims
Request for Reconsideration
Post-Payment Review
Approved Service Locations
Exclusions
Physician’s Role
Physician’s Role for Adults Age 21 and Over
Physician’s Role for Children Under Age 21
Section II-1
Rehabilitative Services for Persons with Mental Illness
224.201
224.202
225.000
226.000
226.100
226.200
227.000
227.001
227.100
227.110
227.111
227.112
228.000
228.100
228.200
228.300
228.310
228.311
228.312
228.313
228.314
228.315
228.316
228.317
228.318
228.320
228.321
228.322
228.330
228.331
228.332
228.333
228.334
228.335
228.400
228.410
228.411
228.412
228.413
228.414
228.415
228.416
229.000
229.100
230.000
231.000
231.001
231.002
231.003
231.100
240.000
240.010
241.000
250.000
Section II
Psychiatric Diagnostic Assessment – Initial
Psychiatric Diagnostic Assessment – Continuing Care
Diagnosis and Clinical Impression
Documentation/Record Keeping Requirements
Reserved
Documentation
Medical Necessity
Prescription for RSPMI Services
Prescription for Speech Therapy
Procedures for Obtaining Extension of Benefits for Speech Therapy
Reconsideration of Extension of Benefits Denial
Appealing an Adverse Action
Provider Reviews
Reserved
Reserved
Record Reviews
On-Site Inspections of Care (IOC)
Purpose of the Review
Provider Notification of IOC
Information Available Upon Arrival of the IOC Team
Cases Chosen for Review
Program Activity Observation
Beneficiary/Family Interviews
Exit Conference
Written Reports and Follow-Up Procedures
DMS/DBHS Work Group Reports and Recommendations
Corrective Action Plans
Actions
Retrospective Reviews
Purpose of the Review
Review Sample and the Record Request
Review Process
Reserved
Reserved
Retrospective Review of Speech Therapy Services for Individuals Under Age 21
Speech-Language Therapy Guidelines for Retrospective Review
Reserved
Reserved
Reserved
Accepted Tests for Speech-Language Therapy
Intelligence Quotient (IQ) Testing
Recoupment Process
Medicaid Beneficiary Appeal Process
Electronic Signatures
PRIOR AUTHORIZATION (PA) AND EXTENSION OF BENEFITS
Introduction to Prior Authorization and Extension of Benefits
Prior Authorization Request for Telemedicine
Prior Authorization Request for Foster Child
Request for Beneficiary Released to DHS Care under Arkansas Code Annotated § 52-315
Prior Authorization and Extension of Benefits
REIMBURSEMENT
Fee Schedule
Rate Appeal Process
BILLING PROCEDURES
Section II-2
Rehabilitative Services for Persons with Mental Illness
251.000
252.000
252.100
252.110
252.130
252.140
252.150
252.200
252.300
252.310
252.400
252.410
252.420
252.430
Section II
Introduction to Billing
CMS-1500 Billing Procedures
Procedure Codes for Types of Covered Services
Outpatient Procedure Codes
Inpatient Hospital Procedure Codes
Telemedicine RSPMI Services Billing Information
Services Available to Residents of Long Term Care Facilities Billing Information
Place of Service Codes
Billing Instructions - Paper Only
Completion of the CMS-1500 Claim Form
Special Billing Procedures
RSPMI Billing Instructions
Non-Covered Diagnosis Codes
Daily Service Billing Exclusions
200.000
REHABILITATIVE SERVICES FOR PERSONS WITH
MENTAL ILLNESS (RSPMI) GENERAL INFORMATION
201.000
Introduction
10-5-09
Medicaid (Medical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining
medical care within the guidelines specified in Section I of this manual. Rehabilitative Services
for Persons with Mental Illness (RSPMI) are covered by Medicaid when provided to eligible
Medicaid beneficiaries by enrolled providers.
RSPMI may be provided to eligible Medicaid beneficiaries at all provider facility certified sites.
Acceptable allowable places of service are found in the service definitions located in Section
252.110.
202.000
Arkansas Medicaid Participation Requirements for RSPMI
3-10-12
In order to ensure quality and continuity of care, all mental 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.
RSPMI 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 Behavioral Health Services (DBHS). (See
Section 202.100 for certification requirements.)
C.
A copy of the current DBHS certification as an RSPMI provider must accompany the
provider application and Medicaid contract.
D.
The provider must give notification to the DMS Program Integrity Unit 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
Section II-3
Rehabilitative Services for Persons with Mental Illness
5.
Home Address
6.
Start Date
7.
End Date (if applicable)
Section II
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 Behavioral Health
Services (DBHS)
7-1-11
Providers of RSPMI Services must furnish documentation of certification from the Division of
Behavioral Health Services (DBHS) establishing that the provider is accredited by the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) Comprehensive
Accreditation Manual for Behavioral Health Care, the Commission on Accreditation of
Rehabilitation Facilities (CARF) Behavioral Health Standards Manual and the Council on
Accreditation (COA) Outpatient Mental Health Services Manual. Accreditation must recognize
and include all the applicant’s programs, services and service sites. Any outpatient behavioral
health program associated with a hospital must have a free-standing behavioral health outpatient
program national accreditation. Providers must meet all other certification requirements in
addition to accreditation.
Certification requirements may be found at www.arkansas.gov/dhs/dmhs/.
202.200
Providers with Multiple Sites
11-1-08
Providers with multiple service sites must apply for enrollment for each site. A cover letter must
accompany the provider application for enrollment of each site that attests to their satellite status
and the name, address and Arkansas Medicaid number of the parent organization.
A letter of attestation must be submitted to the Medicaid Enrollment Unit by the parent
organization annually that lists the name, address and Arkansas Medicaid number of each site
affiliated with the parent. The attestation letter must be received by Arkansas Medicaid no later
than June 15 of each year beginning in June 2009.
Failure by the parent organization to submit a letter of attestation by June 15 each year may
result in the loss of Medicaid enrollment. The Enrollment Unit will verify the receipt of all required
letters of attestation by July 1 of each year. A notice will be sent to any parent organization if a
letter is not received advising of the impending loss of Medicaid enrollment.
210.000
PROGRAM COVERAGE
211.000
Coverage of Services
7-1-11
Section II-4
Rehabilitative Services for Persons with Mental Illness
Section II
Rehabilitative Services for Persons with Mental Illness (RSPMI) are limited to certified providers
who offer core mental health services for the treatment and prevention of mental disorders. The
provider must be certified as an RSPMI provider by the Division of Behavioral Health Services.
An RSPMI provider must establish a site specific emergency response plan that complies with
section VIII (N) of the Arkansas Department of Human Services Division of Behavioral Health
Services Certification Manual. Each site must have 24-hour emergency response capability to
meet the emergency treatment needs of the RSPMI beneficiaries served by the site. The
provider must implement and maintain a written policy reflecting the specific coverage plan to
meet this requirement. An answering machine message to call 911 or report to the nearest
emergency room in and of itself is not sufficient to meet the requirement.
212.000
Quality Assurance
7-1-11
Each RSPMI provider 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 section VIII (P) of the Arkansas Department of Human Services Division of
Behavioral Health Services Certification Manual. Documentation of quality assurance committee
meetings and quality improvement programs must be filed separately from the clinical records.
213.000
Staff Requirements
7-1-11
Each RSPMI provider shall ensure that mental health professionals are available to provide
appropriate and adequate supervision of all clinical activities. RSPMI staff members must
provide services only within the scope of their individual licensure. It is the responsibility of the
facility to credential each clinical staff member, specifying the areas in which he or she can
practice based on training, experience and demonstrated competence.
Each RSPMI provider shall comply with minimum staffing requirements set forth in section VIII
(E) of the Arkansas Department of Human Services Division of Behavioral Health Services
Certification Manual.
In addition to minimum staff requirements, the RSPMI provider may employ additional mental
health professionals who shall meet all professional requirements as defined in the state
licensing and certification laws relating to their respective professions. Examples include:
1.
Psychiatrist
2.
Physician
3.
Psychologist
4.
Psychological Examiner
5.
Adult Psychiatric Mental Health Clinical Nurse Specialist
6.
Child Psychiatric Mental Health Clinical Nurse Specialist
7.
Adult Psychiatric Mental Health Advanced Nurse Practitioner
8.
Family Psychiatric Mental Health Advanced Nurse Practitioner
9.
Master of Social Work (Licensed in the State of Arkansas)
10.
Registered nurse (RN; licensed in the State of Arkansas) who has one (1) year
supervised experience in a mental health setting (Services provided by the RN must
be within the scope of practice specified by the RN’s licensure)
11.
Licensed professional counselor (Licensed in the State of Arkansas)
12.
Persons in a related profession who are licensed in the State of Arkansas and
practicing within the bounds of their licensing authority, with a master's degree and
appropriate experience in a mental health setting, including documented, supervised
Section II-5
Rehabilitative Services for Persons with Mental Illness
Section II
training and experience in diagnosis and therapy of a broad range of mental
disorders
A.
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.
B.
A mental health paraprofessional is defined as a person with a Bachelor's Degree or a
license from the Arkansas State Board of Nursing who does not meet the definition of
mental health professional, but who is licensed and certified by the State of Arkansas in a
related profession and is practicing within the bounds as permitted by his or her licensing
authority, or a person employed by a certified RSPMI provider with a high school diploma
or general equivalency diploma (GED) and documented training in the area of mental
health. A mental health paraprofessional may provide certain Rehabilitative Services for
Persons with Mental Illness under direct supervision of a mental health professional as set
forth in section VIII (E) (4) of the Arkansas Department of Human Services Division of
Behavioral Health Services Certification Manual. The services paraprofessionals may
provide are: crisis stabilization intervention, on-site intervention, off-site intervention,
rehabilitative day service, therapeutic day/acute day treatment and collateral service. If the
paraprofessional is a licensed nurse, the following services may also be provided:
medication administration by a licensed nurse, routine venipuncture for collection of
specimen and catheterization for collection of specimen.
Effective for dates of service on and after October 1, 2008, when an RSPMI provider files a claim
with Arkansas Medicaid, the staff member who actually performed the service on behalf of the
RSPMI provider must be identified on the claim as the performing provider. RSPMI staff
members who are eligible to enroll in the Arkansas Medicaid program have the option of either
enrolling or requesting a Practitioner Identification Number (View or print form DMS-7708) so
that they can be identified on claims. For example, an LCSW may choose to enroll in the
Licensed Mental Health Practitioners program or choose to obtain a Practitioner Identification
Number.
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).
Certain types of practitioners who perform services on behalf of an RSPMI provider cannot enroll
in the Arkansas Medicaid program. These practitioners must request a Practitioner Identification
Number so that they can be identified on claims:
213.010

Psychological Examiner

Adult Psychiatric Mental Health Clinical Nurse Specialist

Child Psychiatric Mental Health Clinical Nurse Specialist

Adult Psychiatric Mental Health Advanced Nurse Practitioner

Family Psychiatric Mental Health Advanced Nurse Practitioner

Master of Social Work (Licensed in the State of Arkansas)

Registered nurse

Paraprofessional
Psychology Interns
9-1-14
Section II-6
Rehabilitative Services for Persons with Mental Illness
Section II
The Division of Medical Services will allow psychology interns to provide limited services under
the following provisions:
RSPMI facilities must retain written documentation of each intern’s:
A.
Enrollment in an American Psychological Association internship program that is fully
accredited or accredited on contingency.
B.
Agreement with the Arkansas Psychology Board regarding oversight and supervision as
defined by the American Psychological Association and the Arkansas Psychology Board
(APB) Rules and Regulations.
Supervision of psychology interns in the RSPMI Program
The psychological procedures covered under the RSPMI Program are allowed as a covered
service when provided by a psychology intern authorized by the Arkansas State Board of
Psychology to provide such psychological services. When a psychology intern provides the
services, the intern must be under the “direct supervision” of the supervising psychologist. For
the purpose of psychological services only, the term “direct supervision” means the following:
A.
The supervising psychologist must monitor and be responsible for the quality of work
performed by the psychology intern under his/her “direct supervision.” The supervising
psychologist must be immediately available to provide assistance and direction throughout
the time the service is being performed. “Immediately available” is defined as the
supervising psychologist being accessible to the psychology intern at any point during the
supervisory relationship.
B
Oversight:
1.
Each supervising psychologist must monitor and be responsible for the quality of the
clinical work assigned to his/her supervisee (intern). Monitoring must include
personal observation of randomly selected patient interactions;
2.
The supervising psychologist must assist and direct the intern in the delivery of
internship services. Assistance and direction must comply with the American
Psychology Association Guidelines and Principles for Accreditation of Programs in
Professional Psychology and the Arkansas Psychology Board Rules and
Regulations;
3.
Internship services will be provided under the license of the supervising psychologist;
and
4.
The supervising psychologist must assure compliance with Medicaid laws, rules, and
regulations, and be accountable for any noncompliance.
As a condition of Medicaid payment, claims must list the supervising psychologist as the
performing provider. Provisions must be made requiring:
A.
The Arkansas Psychology Board to certify in writing that the psychology intern is receiving
training in a qualified internship program for a prescribed period of time and this written
certification shall be retained in the psychology intern’s personnel record; and
B.
The accredited program’s training director to certify in writing and retain in the psychology
intern’s personnel record:
1.
The requirements of the training program in which the intern is participating;
2.
The training dates for each intern;
3.
The name of each participating intern;
4.
The name and Medicaid provider number of:
a. Each participant’s supervising faculty member, or
Section II-7
Rehabilitative Services for Persons with Mental Illness
Section II
b. The Medicaid-enrolled practice clinic in which the supervising faculty member
participates; and
5.
213.100
All services for which a Medicaid claim will be filed are provided under the
supervision of a licensed psychologist who is in good standing with the Arkansas
Psychology Board.
Mental Health Paraprofessional Training
8-1-05
The RSPMI provider is responsible for ensuring all mental health paraprofessionals successfully
complete training in mental health service provision from a licensed medical person experienced
in the area of mental health, a certified RSPMI Medicaid provider, or a facility licensed by the
State Board of Education before providing care to Medicaid beneficiaries.
A.
The mental health paraprofessional must receive orientation to the RSPMI provider
agency.
B.
The mental health paraprofessional training course 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 RSPMI provider agency.
C.
The training curriculum must contain information specific to the population being served,
i.e. child and adolescent, adult, dually diagnosed, etc. The curriculum must include, but is
not limited to:
D.
1.
Communication skills.
2.
Knowledge of mental 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.
A written examination of the mental health paraprofessional’s knowledge of the 40-hour
classroom training curriculum must be successfully completed.
Section II-8
Rehabilitative Services for Persons with Mental Illness
Section II
E.
Evaluation of the mental health paraprofessional’s ability to perform daily living skills (DLS)
for mental health services must be successfully completed by means of a skills test.
F.
The paraprofessional 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 mental health paraprofessional.
G.
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. The in-service training
must total a minimum of eight (8) hours each 12-month period beginning with the date of
certification as a paraprofessional and each 12-month period thereafter. The in-service
training may be conducted, in part, in the field. Documentation of in-service hours will be
maintained in the employee’s personnel record and will be available for inspection by
regulatory agencies.
A mental health paraprofessional who can provide documentation of training or experience in
mental health service delivery may be exempt from the 40-hour classroom training. This does
not exclude the paraprofessional from the requirement of successfully completing an
examination and skills test.
All mental health paraprofessionals who provided mental health services for a Medicaid certified
RSPMI provider on or before October 1, 1989, and since November 1, 1988, will be certified as
mental health paraprofessionals. These mental health paraprofessionals may be exempt from
the 40-hour classroom training. However, a written examination of the mental health
paraprofessional’s knowledge of the 40-hour training course must be successfully completed
and an evaluation of his or her ability to perform the daily living skills must be successfully
completed by means of a skills test. A certificate must be awarded to the mental health
paraprofessional and available for review by the Division of Medical Services staff upon request.
214.000
Facility Requirements
10-13-03
The administration of the program shall be responsible for providing physical facilities that are
structurally sound and meet all applicable federal, state and local regulations for adequacy of
construction, safety, sanitation and health.
215.000
Non-Refusal Requirement
10-13-03
The RSPMI provider may not refuse services to a Medicaid-eligible beneficiary who meets the
requirements for RSPMI services as outlined in this manual unless, based upon the primary
mental health diagnosis, the provider does not possess the services or program to adequately
treat the beneficiary’s mental health needs.
216.000
Scope
6-1-05
A range of mental health rehabilitative or palliative services is provided by a duly certified RSPMI
provider to Medicaid-eligible beneficiaries suffering from mental illness, as described in the
American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV and subsequent
revisions).
Rehabilitative Services for Persons with Mental Illness may be covered only when:
A.
Provided by qualified providers,
B.
Approved by a physician within 14 calendar days of entering care,
C.
Provided according to a written treatment plan/plan of care, and
D.
Provided to outpatients only except as described in Section 252.130.
E.
In order to be valid, the treatment plan/plan of care must:
Section II-9
Rehabilitative Services for Persons with Mental Illness
Section II
1.
Be prepared according to guidelines developed and stipulated by the organization’s
accrediting body and
2.
Be signed and dated by the physician who certifies medical necessity.
If the beneficiary receives care under the treatment plan, the initial treatment
plan/plan of care must be approved by the physician within 14 calendar days of the
initial receipt of care.
The physician’s signature is not valid without the date signed.
217.000
RSPMI Program Entry
6-1-05
Prior to providing treatment services, an intake evaluation must be performed for each
beneficiary being considered for entry into a RSPMI Program. The evaluation is a written
assessment that evaluates the beneficiary’s mental condition and, based on the beneficiary’s
diagnosis, determines whether treatment in the RSPMI Program would be appropriate. The
assessment must be made a part of the beneficiary’s records.
The intake evaluation must be conducted by a mental health professional qualified by licensure
and experienced in the diagnosis and treatment of mental illness.
For each beneficiary served through the RSPMI Program, the treatment team must certify that
the program is appropriate to meet the beneficiary’s needs. This certification must be
documented in the beneficiary record within 14 calendar days of the person’s entering continued
care (first billable service), through treatment team signatures on the treatment plan/plan of care.
The treatment team must include, at a minimum, a physician and an individual qualified, by
licensure and experience, in diagnosis and treatment of mental illness. (Both criteria may be
satisfied by the same individual, if appropriately qualified.)
217.010
A.
Follow-up to Missed Beneficiary Appointments and Discharges
3-1-14
For beneficiaries not certified as being Seriously Mentally Ill (SMI) or Seriously
Emotionally Disturbed (SED):
If the beneficiary misses a professional appointment without notifying the provider to
reschedule within 14 days, then the facility must notify the beneficiary to determine
whether the beneficiary desires further treatment and, if so, with a request that they
reschedule the appointment. Notification must occur in writing, by electronic contact or by
telephone and must inform beneficiaries that they will be discharged within 90 days if they
choose not to reschedule. Beneficiaries should be advised that services are available
anytime in the future upon their request, based upon continuing need. Community
resources or referrals if needed or requested must be provided. All contacts and results
must be documented in the beneficiary’s medical record.
B.
For beneficiaries certified as being Seriously Mentally Ill (SMI) or Seriously Emotionally
Disturbed (SED):
If the beneficiary misses a professional appointment without notifying the provider, then the
contacts or attempts must be made by a member of the treatment team or by
administrative staff who are under the supervision of the Mental Health Professional
(MHP). All documentation related to the contacts and subsequent discharge must be in
the beneficiary’s medical record. If the beneficiary misses a professional appointment
without notifying the provider to reschedule, then the facility must accomplish follow-up by
making contacts in the following order twice in the 90-day period prior to discharge:
1.
Telephone or electronic contact no later than 7 calendar days after a missed
appointment
Section II-10
Rehabilitative Services for Persons with Mental Illness
2.
Section II
A letter to the beneficiary, family members or other responsible parties within 14
calendar days of the missed appointment if there is no response to the telephone or
electronic attempt.
The above two contacts must be repeated twice in the 90-day period prior to discharge. If
there is no response to the above follow-up contact attempts, the facility must repeat the
above contacts (a telephone or electronic contact and, if no response to the telephone or
electronic contact, send a letter to the beneficiary, family members or other responsible
parties) prior to discharging the beneficiary.
Discharge and readmission procedures
No later than the 90th day after the last failed appointment, if all efforts to engage the beneficiary
in treatment have been unsuccessful, then an official letter must be sent to the beneficiary
outlining the reason for discharge and advising the beneficiary that services are available
anytime in the future upon request based on continuing need.
The beneficiary’s physician must be informed of all problems with engagement for further input.
When a beneficiary fails to keep an appointment which precipitates a high risk clinical situation
that cannot be resolved by the treatment team, then referral shall be made to the provider’s
Quality Assurance Committee. The Quality Assurance Committee’s decision must be
documented in the beneficiary’s medical record and in the minutes.
If the beneficiary returns following a discharge for dropping out of services, but prior to the
expiration of the Psychiatric Diagnostic Assessment, then the beneficiary may resume treatment
and be readmitted with a Mental Health Professional Intervention and/or Pharmacologic
Management and a Periodic Review of the Treatment Plan occurring within 14 days of reentering
care. All treatment planning timelines will resume.
217.020
Reserved
217.100
Primary Care Physician (PCP) Referral
10-1-15
8-1-05
A PCP referral is required for individuals under age 21 for RSPMI services except those listed in
Section 217.111. Verbal referrals from PCP's 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.
217.111
Procedure Codes Not Requiring PCP Referral for Beneficiaries
Under Age 21
9-1-13
Services designated by the following procedure codes and modifiers do not require PCP
referral:
A.
90791, HA, U1 – Mental Health Evaluation/Diagnosis
B.
90885, HA, U2 – Master Treatment Plan
C.
90887, HA, U2 – Interpretation of Diagnosis
D.
H2011, HA – Crisis Intervention
E.
90792, HA, U1 – Psychiatric Diagnostic Assessment – Initial
F.
90792, U7 – Psychiatric Diagnostic Assessment – Initial (telemedicine)
G.
90792, HA, U2 – Psychiatric Diagnostic Assessment – Continuing Care
H.
90792, U7, U1 – Psychiatric Diagnostic Assessment – Continuing Care (telemedicine)
Section II-11
Rehabilitative Services for Persons with Mental Illness
217.112
Section II
8-1-05
Medicaid Eligible at the Time the Service is Provided
A PCP referral is required. The referral is recommended prior to providing service to Medicaideligible children. However, a PCP is given the option of providing a referral after a service is
provided. If a PCP chooses to make a referral after a service has been provided, the referral
must be received by the RSPMI provider no later 45 calendar days after the date of service. The
PCP has no obligation to give a retroactive referral.
The RSPMI provider may not file a claim and will not be reimbursed for any services provided
that require a PCP referral unless the referral is received. If the PCP declines to provide the
referral retroactive to the date of service, services may be billed beginning the date he/she
completes the referral, or the date shown on the referral as the approved date. Medicaid will not
cover the services provided prior to the date approved by the PCP. See Section 171.400.
217.113
8-1-05
Medicaid Ineligible at the Time the Service is Provided
A.
When a child who is not eligible for Medicaid receives an outpatient mental health service,
an application for Medicaid eligibility may be filed by the child or his or her representative.
B.
If the application for Medicaid coverage is approved, a PCP referral is not required for the
period prior to the Medicaid authorization date. This period is considered retroactive
eligibility and does not require a referral.
C.
A PCP referral is required no later than forty-five calendar days after the authorization
date. If the PCP referral is not obtained within forty-five calendar days of the Medicaid
authorization date, reimbursement will begin (if all other requirements are met) for services
provided upon eligibility authorization and after, the date the PCP referral is received.
A PCP is given the option of providing a referral after a service is provided. However, the
PCP has no obligation to give a retroactive referral. The RSPMI provider may not file a
claim and will not be reimbursed for any services provided that require a PCP referral
unless the referral has been received. See Section 171.400.
To verify the authorization date, a provider may call Hewlett Packard Enterprise or the local
DHS office. View or print Hewlett Packard Enterprise PAC contact information. View
or print the DHS office contact information.
218.000
Master Treatment Plan
10-4-09
For each beneficiary entering the RSPMI Program, the treatment team must develop an
individualized master treatment plan. This consists of a written, individualized plan to treat,
ameliorate, diminish or stabilize or maintain remission of symptoms of mental illness that
threaten life, or cause pain or suffering, resulting in diminished or impaired functional capacity.
The master treatment plan goals and objectives must be based on problems identified in the
intake assessment or in subsequent assessments during the treatment process. The master
treatment plan must be included in the beneficiary records and contain a written description of
the treatment objectives for that beneficiary. It also must describe:
A.
The treatment regimen—the specific medical and remedial services, therapies and
activities that will be used to meet the treatment objectives;
B.
A projected schedule for service delivery—this includes the expected frequency and
duration of each type of planned therapeutic session or encounter;
C.
The type of personnel that will be furnishing the services and
D.
A projected schedule for completing reevaluations of the patient’s condition and updating
the master treatment plan.
Section II-12
Rehabilitative Services for Persons with Mental Illness
Section II
The RSPMI master treatment plan must be completed by a mental health professional and
approved by a psychiatrist or physician, within 14 calendar days of the individual’s entering care
(first billable service). Subsequent revisions in the master treatment plan will be approved in
writing (signed and dated) by the psychiatrist or physician verifying continued medical necessity.
218.001
Participation of Families and Children in the Development of the
Treatment Plan for Children Under Age 21
7-1-08
The treatment plan should be based on the beneficiary’s (or the parents’ or guardians’ if the
beneficiary is under the age of 18) articulation of the problems or needs to be addressed in
treatment. Each problem or need must have one or more clearly defined behavioral goals or
objectives that will allow the beneficiary, family members, provider agency staff and others to
assess progress toward achievement of the goal or objective. For each goal or objective, the
treatment plan must specify the treatment intervention(s) determined to be medically necessary
to address the problem or need and to achieve the goal(s) or objective(s).
The treatment plan must specify the beneficiary’s and family’s strengths and natural supports
that will be the foundation for the treatment plan. The beneficiary, parent or guardian must be
provided an opportunity to express comments about the treatment plan and a space on the
treatment plan form to record these comments. The treatment plan must be signed by the MHP
who drafted the plan, the physician authorizing and supervising the treatment, agency staff
members who will provide specific treatment interventions, the beneficiary (unless clinically or
developmentally contra-indicated) and, for beneficiaries under the age of 18, a parent or legal
guardian.
If the parent, guardian or custodian for beneficiaries under the age of 18 is not available to
provide a signature on the treatment plan, the client record must have documentation indicating
barriers to obtaining that signature within 14 calendar days of the treatment plan.
Documentation, either on the treatment plan form or in a progress note must include the method
of communication with the parent or guardian and must include a description of the parent or
guardian’s input on treatment goals and services to be provided and the role and/or involvement
of the parent or guardian in ongoing treatment services provided for the beneficiary.
218.100
Periodic Treatment Plan Review
5-1-08
The RSPMI treatment plan must be periodically reviewed by the treatment team in order to
determine the beneficiary’s progress toward the rehabilitative treatment and care objectives, the
appropriateness of the rehabilitative services provided and the need for the enrolled beneficiary’s
continued participation in the RSPMI Program. The reviews must be performed on a regular
basis (at least every 90 calendar days), documented in detail in the enrolled beneficiary’s record,
kept on file and made available as requested for state and federal purposes. If provided more
frequently, there must be documentation of significant acuity or change in clinical status requiring
an update in the beneficiary’s treatment plan. The clock for the 90-day review begins to run on
the earliest date set forth on the form that contains the treatment plan.
218.101
Participation of Families and Children in the Periodic Review of the
Treatment Plan for Children Under Age 21
7-1-08
The review of the treatment plan must reflect the beneficiary’s, or in the case of a beneficiary
under the age of 18, the parent’s or guardian’s, assessment of progress toward meeting
treatment goals or objectives and their level of satisfaction with the treatment services provided.
Problems, needs, goals, objectives, strengths and supports should be revised based on the
progress made, barriers encountered, changes in clinical status and any other new information.
The beneficiary, the parent or the guardian must be provided an opportunity to express
comments about the treatment plan and a space on the treatment plan form to record these
comments and their level of satisfaction with the services provided. The review of the plan of
care must be signed by the MHP who drafted the plan, the physician authorizing and supervising
the treatment, agency staff members who will provide specific treatment interventions, the
Section II-13
Rehabilitative Services for Persons with Mental Illness
Section II
beneficiary (unless clinically or developmentally contra-indicated) and a parent or legal guardian
for beneficiaries under the age of 18.
If the parent or legal guardian for beneficiaries under the age of 18 is not available to provide a
signature on the review of the treatment plan, the client record must have documentation
indicating barriers to obtaining that signature within 14 calendar days of the the treatment plan
review. Documentation, either on the review of treatment plan form or in a progress note must
include the method of communication with the parent or guardian regarding the parent’s or legal
guardian’s perception on treatment progress and services provided, revisions needed to the
treatment plan and involvement of the parent or guardian in ongoing treatment services provided
for the beneficiary.
219.000
Covered Services
10-13-03
The RSPMI services listed below are available to Medicaid-eligible beneficiaries whose primary
diagnosis is mental illness. When the primary diagnosis is other than mental illness, e.g.,
substance abuse, RSPMI services are not covered by Arkansas Medicaid.
219.100
Outpatient Services
10-4-09
RSPMI outpatient services, based on a plan of care, include a broad range of services to
Medicaid-eligible beneficiaries. Beneficiaries shall be served with an array of treatment services
outlined on their individualized master treatment plan in an amount and duration designed to
meet their medical needs.
219.110
Daily Limit of Beneficiary Services
10-4-09
Medicaid Beneficiaries will be limited to a maximum of eight hours per 24 hour day of outpatient
services with the exception of Crisis Intervention, Crisis Stabilization Intervention by Mental
Health Professional and Crisis Stabilization Intervention by Mental Health Paraprofessional.
Beneficiaries will be eligible for an extension of the daily maximum amount of services based on
a medical necessity review by the contracted utilization management entity (See Section
231.100 for details regarding extension of benefits).
219.130
Routine Venipuncture for Collection of Specimen
10-13-03
A specimen collection may only be provided to patients taking prescribed psychotropic drugs or
who are involved in drug abuse as verified through the diagnosis procedure.
This service must be performed by a physician or a licensed nurse under the direction of a
physician. Arkansas Medicaid policy regarding collection, handling and/or conveyance of
specimens is as follows:
A.
Reimbursement is not available for specimen handling fees.
B.
A specimen collection fee is covered only for:
C.
219.140
1.
Drawing a blood sample through venipuncture (i.e., inserting a needle into a vein to
draw the specimen with a syringe or vacutainer) or
2.
Collecting a urine sample by catheterization.
Specimen collection is covered only when the specimen collected is sent to a reference
laboratory for tests. Reimbursement for collection of specimen is included in the
reimbursement for lab tests when the practitioner, clinic or facility that collects the
specimen performs the tests.
Telemedicine (Interactive Electronic Transactions) RSPMI Services
5-15-12
Section II-14
Rehabilitative Services for Persons with Mental Illness
Section II
RSPMI telemedicine services are interactive electronic transactions performed “face-to-face” in
real time, via two-way electronic video and audio data exchange.
Reimbursement for telemedicine services is only available when, at a minimum, the Arkansas
Telehealth Network (ATN) recommended audio video standards for real-time, two-way
interactive audiovisual transmissions are met. Those standards are:
A.
Minimum bandwidth of fractional T1 (728 kilobytes);
B.
Screen size of no less than 20 inch diagonal;
C.
Transmitted picture frame rate capable of 30 frames per second at 384Kbps and the
transmitted picture frame rate is suitable for the intended application; and
D.
All applicable equipment is UL and FCC Class A approved.
Providers who provide telemedicine services for Medicaid-eligible beneficiaries must be able to
link or connect to the Arkansas Telehealth Network to ensure HIPAA compliance. Sites
providing reimbursable telemedicine services to Medicaid-eligible beneficiaries are required to
demonstrate the ability to meet the ATN standards listed above. A site must be certified by ATN
before telemedicine services can be conducted. ATN will conduct site visits at initial start-up to
ensure that all standards are met and to certify each telemedicine site. ATN will view
connectivity statistics in order to ensure that appropriate bandwidth is being utilized by sites and
will conduct random site visits to ensure that providers continue to meet all recommended
standards and guidelines.
The mental health professional may provide certain treatment services from a remote site to the
Medicaid-eligible beneficiary who is located in a mental health clinic setting. There must be an
employee of the clinic in the same room with the beneficiary. Refer to Section 252.140 for billing
instructions.
The following services may be provided via telemedicine by a mental health professional to
Medicaid-eligible beneficiaries under age 21 and Medicaid-eligible beneficiaries age 21 and
over:
A.
Psychiatric Diagnostic Assessment – Initial
B.
Psychiatric Diagnostic Assessment – Continuing Care
C.
Pharmacologic Management by Physician
The following services may be provided via telemedicine by a mental health professional to
Medicaid-eligible beneficiaries age 21 and over:
A.
Mental Health Evaluation/Diagnosis
B.
Interpretation of Diagnosis
C.
Individual Psychotherapy
D.
Marital/Family Psychotherapy – Beneficiary is not present
E.
Marital/Family Psychotherapy – Beneficiary is present
F.
Crisis Intervention
G.
Crisis Stabilization Intervention, Mental Health Professional
H.
Collateral Intervention, Mental Health Professional
I.
Intervention, Mental Health Professional
Section II-15
Rehabilitative Services for Persons with Mental Illness
219.141
Services Available to Residents of Long Term Care Facilities
Section II
10-5-09
The following RSPMI services may be provided to residents of nursing homes and ICF/IID
facilities who are Medicaid eligible when the services are prescribed according to policy
guidelines detailed in this manual:
A.
Mental Health Evaluation/Diagnosis,
B.
Psychological Evaluation,
C.
Pharmacologic Management by Physician,
D.
Master Treatment Plan,
E.
Periodic Review of Master Treatment Plan,
F.
Interpretation of Diagnosis,
G.
Individual Psychotherapy,
H.
Crisis Intervention.
Services provided to nursing home and ICF/IID residents may be provided on- or off-site from
the RSPMI provider if allowable per the service definition. Some services may be provided in the
long-term care (LTC) facility, if necessary.
220.000
Inpatient Hospital Services
10-13-03
“Inpatient” means a patient who has been admitted to a medical institution on recommendation
of a licensed practitioner authorized to admit patients; and who is receiving room, board and
professional services in the institution on a continuous 24-hour-a-day basis; or who is expected
by the institution to receive room, board and professional services for 24 hours or longer.
220.100
Hospital Visits
10-13-03
Inpatient hospital visits are Medicaid covered only for board certified or board eligible
psychiatrists employed by the RSPMI provider. Each attending physician is limited to billing one
day of care for an inpatient hospital Medicaid covered day, regardless of the number of hospital
visits made by the physician.
A “Medicaid covered day” is defined as a day for which the patient is Medicaid eligible, the
patient’s inpatient benefit limit has not been exhausted, the patient’s inpatient stay is medically
necessary, the day is not part of a hospital stay for a non-payable procedure or non-authorized
procedure and the claim is filed on time. (See Section III of this manual for information regarding
“Timely Filing.”)
220.200
Inpatient Hospital Services Benefit Limit
10-13-03
There is no inpatient benefit limit for Medicaid-eligible individuals under age 21. The benefit limit
for general and rehabilitative hospital inpatient services is 24 paid inpatient days per state fiscal
year (July 1 through June 30) for Medicaid beneficiaries aged 21 and older. Extension of this
benefit is not available.
221.000
Medicaid Utilization Management Program (MUMP)
10-13-03
Section II-16
Rehabilitative Services for Persons with Mental Illness
Section II
The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in
inpatient, general and rehabilitative hospitals, both in state and out of state. The MUMP does
not apply to lengths of stay in psychiatric facilities.
Lengths-of-stay determinations are made by the Quality Improvement Organization (QIO),
Arkansas Foundation for Medical Care, Inc., (AFMC) under contract to the Arkansas Medicaid
Program.
221.100
MUMP Applicability
10-13-03
A.
Medicaid covers up to four (4) days of inpatient service with no certification requirement,
except in the case of a transfer (see subpart B, below). If a patient is not discharged
before or during the fifth day of hospitalization, additional days are covered only if certified
by AFMC.
B.
When a patient is transferred from one hospital to another, the stay in the receiving
hospital must be certified from the first day.
221.110
MUMP Exemptions
10-13-03
A.
Individuals in all Medicaid eligibility categories and all age groups, except beneficiaries
under age one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at
the time of admission are exempt from the MUMP policy for dates of service before their
first birthday.
B.
MUMP policy does not apply to inpatient stays for bone marrow, liver, heart, lung, skin and
pancreas/kidney transplant procedures.
221.200
MUMP Procedures
10-13-03
MUMP procedures are detailed in the following sections of this manual:
A.
Direct (non-transfer) admissions – Section 221.210
B.
Transfer admissions – Section 221.220
C.
Certifications of inpatient stays involving retroactive eligibility – Section 221.230
D.
Inpatients with third party or Medicare coverage – Section 221.240
E.
Reconsideration reviews of denied extensions – Section 221.250
221.210
A.
Direct Admissions
10-13-03
When the attending physician determines the patient should not be discharged by the fifth
day of hospitalization, a hospital medical staff member may contact AFMC and request an
extension of inpatient days. View or print AFMC contact information. The following
information is required:
1.
Patient name and address (including ZIP code),
2.
Patient birth date,
3.
Patient Medicaid number,
4.
Admission date,
5.
Hospital name,
6.
Hospital Medicaid provider number,
7.
Attending physician Medicaid provider number,
Section II-17
Rehabilitative Services for Persons with Mental Illness
B.
Section II
8.
Principal diagnosis and other diagnosis influencing this stay,
9.
Surgical procedures performed or planned,
10.
The number of days being requested for continued inpatient stay and
11.
All available medical information justifying or supporting the necessity of continued
stay in the hospital.
Calls for extension of days may be made at any time during the inpatient stay (except in
the case of a transfer from another hospital–refer to Section 221.220).
1.
Providers initiating their request after the fourth day must accept the financial liability
should the stay not meet necessary medical criteria for inpatient services.
2.
When the provider delays calling for extension verification and the services are
denied based on medical necessity, the beneficiary may not be held liable.
3.
If the fifth day of admission falls on a Saturday, Sunday or holiday, it is
recommended that the hospital provider call for an extension prior to the fifth day, if
the physician has recommended a continued stay.
C.
When a Medicaid beneficiary reaches age one (1) during an inpatient stay, the days from
the admission date through the day before the patient’s birthday are exempt from the
MUMP policy. MUMP policy becomes effective on the one-year birthday. The patient’s
birthday is the first day of the four days not requiring MUMP certification. If the stay
continues beyond the fourth day following the patient’s first birthday, hospital staff must
apply for MUMP certification for the additional days.
D.
AFMC utilizes Medicaid guidelines and the medical judgment of its professional staff to
determine the number of days to allow.
E.
AFMC assigns an authorization number to an approved extension request and sends
written notification to the hospital.
F.
Additional extensions may be requested as needed.
G.
The certification process under the MUMP is separate from prior authorization
requirements. Prior authorization for medical procedures thus restricted must be obtained
by the appropriate providers. Hospital stays for restricted procedures may be disallowed if
required prior authorizations are not obtained.
H.
Claims submitted without calling for an extension request will result in automatic
denials of any days billed beyond the fourth day. There will be no exceptions
granted except for claims reflecting third party liability.
221.220
Transfer Admissions
10-13-03
If a patient is transferred from one hospital to another, the receiving facility must contact AFMC
within 24 hours of admitting the patient to certify the inpatient stay. If admission falls on a
weekend or holiday, the provider may contact AFMC on the first working day following the
weekend or holiday.
221.230
Retroactive Eligibility
10-13-03
A.
If eligibility is determined while the patient is still an inpatient, the hospital may call to
request post-certification of inpatient days beyond the first four (4) (or all days if the
admission was by transfer) and a concurrent certification of additional days, if needed.
B.
If eligibility is determined after discharge, the hospital may call AFMC for post-certification
of inpatient days beyond the first four (4) (or all days if the admission was by transfer). If
Section II-18
Rehabilitative Services for Persons with Mental Illness
Section II
certification sought is for a stay longer than 30 days, the provider must submit the entire
medical record to AFMC for review.
221.240
A.
B.
221.250
Third Party and Medicare Primary Claims
10-13-03
If a provider has not requested MUMP certification of inpatient days because there is
apparent coverage by insurance or Medicare Part A, but the other payer has denied the
claim for non-covered service, lost eligibility, benefits exhausted, etc., post-certification
required by the MUMP may be obtained as follows:
1.
Send a copy of the third party payer’s denial notice to AFMC, attention PreCertification Supervisor. View or print AFMC contact information.
2.
Include a written request for post-certification.
3.
Include complete provider contact information: full name and title, telephone number
and extension.
4.
An AFMC coordinator will call the provider contact for the certification information.
If a third party insurer pays the provider for an approved number of days, Medicaid will not
grant an extension for days beyond the number of days approved by the private insurer.
Request for Reconsideration
10-13-03
Reconsideration reviews of denied extensions may be expedited by faxing the medical record to
AFMC. AFMC will advise the hospital of its decision by the next working day. View or print
AFMC contact information.
221.260
Post-Payment Review
10-13-03
A post payment review of a 30% random sample is conducted on all admissions, including
inpatient stays of four days or less, to ensure that medical necessity for the services is
substantiated.
222.000
Approved Service Locations
10-13-03
Rehabilitative Services for Persons with Mental Illness (RSPMI) are covered by Medicaid only in
the outpatient setting, except for inpatient hospital visits by board-certified psychiatrists.
The services and procedure codes available for billing for RSPMI providers are listed in Section
250.000 of this manual.
223.000
Exclusions
10-4-09
Services not covered under the RSPMI Program include, but are not limited to:
A.
Room and board residential costs;
B.
Educational services;
C.
Telephone contacts with patient or collateral;
D.
Transportation services, including time spent transporting a beneficiary for services
(reimbursement for other RSPMI 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,
except for testing purposes;
F.
RSPMI services which are found not to be medically necessary and
Section II-19
Rehabilitative Services for Persons with Mental Illness
G.
Section II
RSPMI services provided to nursing home and ICF/IID residents other than those specified
in Section 252.150.
224.000
Physician’s Role
224.100
Physician’s Role for Adults Age 21 and Over
3-10-12
RSPMI providers are required to have a board certified or board eligible psychiatrist who
provides appropriate supervision and oversight for all medical and treatment services provided
by the agency. A physician will supervise and coordinate all psychiatric and medical functions as
indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in
Arkansas, preferably one specializing in psychiatry. If medical responsibility is not vested in a
psychiatrist, then psychiatric consultation must be available. For RSPMI enrolled adults age 21
and over, medical supervision responsibility shall include, but is not limited to, the following:
A.
For any beneficiary certified as being Seriously Mentally Ill (SMI), the physician will perform
an initial Psychiatric Diagnostic Assessment during the earlier of 45 days of the beneficiary
entering care or 45 days from the effective date of certification of serious mental illness.
This initial evaluation is not required if the beneficiary discontinues services prior to
calendar day 45. The SMI beneficiary must receive a continuing care Psychiatric
Diagnostic Assessment within one year after the date of the initial Psychiatric Diagnostic
Assessment and at least every year thereafter.
B.
For beneficiaries not certified as having a Serious Mental Illness, the physician may
determine through review of beneficiary records and consultation with the treatment staff
that it is not medically necessary to directly see the enrolled beneficiary. By calendar day
45 after entering care, the physician must document in the beneficiary’s record that it is not
medically necessary to see the beneficiary. If the beneficiary continues to be in care for
more than six months after program entry, the psychiatrist/physician must conduct an initial
Psychiatric Diagnostic Assessment of the beneficiary by the end of six months and perform
a continuing care Psychiatric Diagnostic Assessment at least every 12 months thereafter.
C.
The physician will review and approve the enrolled beneficiary’s RSPMI treatment plan and
document approval in the enrolled beneficiary’s record. If the treatment plan is revised
prior to each 90 day interval, the physician must approve the changes within 14 calendar
days, as indicated by a dated signature on the revised plan.
D.
Approval of all updated or revised treatment plans must be documented by the physician’s
dated signature on the revised document. The new 90-day period begins on the date the
revised treatment plan is completed.
224.200
Physician’s Role for Children Under Age 21
3-10-12
RSPMI providers are required to have a board certified or board eligible psychiatrist who
provides supervision and oversight for all medical and treatment services provided by the
agency. A physician will supervise and coordinate all psychiatric and medical functions as
indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in
Arkansas, preferably one specializing in psychiatry. If medical responsibility is not vested in a
psychiatrist, then psychiatric consultation must be available on a regular basis. For RSPMI
enrolled children, under age 21, medical supervision responsibility shall include, but is not limited
to, the following:
A.
For any beneficiary under age 18, certified as being Seriously Emotionally Disturbed (SED)
or individuals age 18 through age 20 certified as Seriously Mentally Ill (SMI), the physician
will conduct an initial Psychiatric Diagnostic Assessment of the beneficiary the earlier of 45
days of the individual’s entering care or 45 days from the effective date of certification of
serious mental illness/serious emotional disturbance. This initial evaluation is not required
if the beneficiary discontinues services prior to calendar day 45. The SMI/SED beneficiary
Section II-20
Rehabilitative Services for Persons with Mental Illness
Section II
must be evaluated again directly by the physician through the Psychiatric Diagnostic
Assessment – Continuing Care within 12 months after the date of the initial examination
and every 12 months after (at a minimum) during an episode of care..
B.
For beneficiaries not certified as having a Serious Mental Illness or Serious Emotional
Disturbance, the psychiatrist or physician may determine through review of beneficiary
records and consultation with the treatment staff that it is not medically necessary to
directly assess and interview the enrolled beneficiary. By calendar day 45 after entering
care, the physician must document in the beneficiary’s record that it is not medically
necessary to provide the beneficiary a physician assessment. If the beneficiary continues
to be in care for more than six months after program entry, the psychiatrist/physician must
conduct an initial Psychiatric Diagnostic Assessment of the beneficiary by the end of six
months and perform a continuing care Psychiatric Diagnostic Assessment at least every 12
months thereafter.
C.
The physician will review and approve the enrolled beneficiary’s RSPMI treatment plan and
document the approval in the enrolled beneficiary’s record. If the treatment plan is revised
prior to each 90 day interval, the physician must approve the changes within 14 calendar
days, as indicated by a dated signature on the revised plan.
D.
Approval of all updated or revised treatment plans must be documented by the physician’s
dated signature on the revised document. The new 90-day period begins on the date the
revised treatment plan is completed.
Psychiatric Diagnostic Assessment – Initial
224.201
12-15-14
The purpose of this service is to determine the existence, type, nature and most appropriate
treatment of a mental illness or emotional disorder as defined by DSM-IV or ICD. This face-toface psycho diagnostic assessment must be conducted by one of the following:

an Arkansas-licensed physician, preferably one with specialized training and experience
in psychiatry (child and adolescent psychiatry for beneficiaries under age 18)

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:

Licensed by the Arkansas State Board of Nursing

Practicing with licensure through the American Nurses Credentialing Center

Practicing under the supervision of an Arkansas-licensed psychiatrist who has an
affiliation with the RSPMI program and with whom the PMHNP-BC has a collaborative
agreement. The findings of the Psychiatric Diagnostic Assessment – Initial 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.

Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act

Practicing within a PMHNP-BC’s experience and competency level
The initial Psychiatric Diagnostic Assessment must include:
A.
An interview with the beneficiary, which covers the areas outlined below. The initial
Psychiatric Diagnostic Assessment may build on information obtained through other
assessments reviewed by the physician or the PMHNP-BC and verified through the
Section II-21
Rehabilitative Services for Persons with Mental Illness
Section II
physician’s or the PMHNP-BC’s interview. The interview should obtain or verify all of the
following:
B.
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)
The initial Psychiatric Diagnostic Assessment must include:
C.
1.
A mental status evaluation (a developmental mental status evaluation for
beneficiaries under age 18)
2.
A complete multi-axial (5) diagnosis
For beneficiaries under the age of 18, the initial Psychiatric Diagnostic Assessment must
also include 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:
1.
Clarify the reason for referral
2.
Clarify the nature of the current symptoms and functional impairments
3.
To obtain a detailed medical, family and developmental history
The initial Psychiatric Diagnostic Assessment must contain sufficient detailed information to
substantiate all diagnoses specified in the assessment and treatment plan, all functional
impairments listed on SED or SMI certifications and all problems or needs to be addressed on
the treatment plan. The initial Psychiatric Diagnostic Assessment is for new patients only.
Only one (1) Psychiatric Diagnostic Assessment (whether Initial or Continuing Care) is allowed
per State Fiscal Year.
Psychiatric Diagnostic Assessment – Continuing Care
224.202
12-15-14
The purpose of this service is to determine the continuing existence, type, nature and most
appropriate treatment of a mental illness or emotional disorder as defined by DSM-IV or ICD.
This face-to-face psycho diagnostic reassessment must be conducted by one of the following:

an Arkansas-licensed physician, preferably one with specialized training and experience
in psychiatry (child and adolescent psychiatry for beneficiaries under age 18)

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:

Licensed by the Arkansas State Board of Nursing

Practicing with licensure through the American Nurses Credentialing Center

Practicing under the supervision of an Arkansas-licensed psychiatrist who has an
affiliation with the RSPMI program and with whom the PMHNP-BC has a collaborative
agreement. Prior to the initiation of the treatment plan, the findings of the Psychiatric
Diagnostic Assessment – Continuing Care conducted by the PMHNP-BC must be
discussed with the supervising psychiatrist. The collaborative agreement must comply
Section II-22
Rehabilitative Services for Persons with Mental Illness
Section II
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.

Practicing within the scope of practice as defined by the Arkansas Nurse Practice Act

Practicing within a PMHNP-BC’s experience and competency level
The continuing care Psychiatric Diagnostic Assessment must include:
A.
B.
C.
An interview with the beneficiary, which covers the areas outlined below. The continuing
care Psychiatric Diagnostic Assessment may build on information obtained through other
assessments reviewed by the physician or the PMHNP-BC and verified through the
physician’s or the PMHNP-BC’s interview. The interview should obtain or verify all of the
following:
1.
Psychiatric assessment (including current symptoms and functional impairments)
2.
Medications and responses
3.
Response to current treatment interventions
4.
Medical history (and examination, as indicated)
The continuing care Psychiatric Diagnostic Assessment must also include:
1.
A mental status evaluation (a developmental mental status evaluation for
beneficiaries under age 18)
2.
A complete multi-axial (5) diagnosis
For beneficiaries under the age of 18, the continuing care Psychiatric Diagnostic
Assessment must include 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:
1.
Clarify the nature of the current symptoms and functional impairments
2.
Obtain a detailed, updated medical, family and developmental history
The continuing care Psychiatric Diagnostic Assessment must contain sufficient detailed
information to substantiate all diagnoses specified in the continuing care assessment and
updated treatment plan, all functional impairments listed on SED or SMI certifications and all
problems or needs to be addressed on the treatment plan. The continuing care Psychiatric
Diagnostic Assessment is for established patients only. The continuing care Psychiatric
Diagnostic Assessment must be performed, at a minimum, every 12 months for established
patients.
Only one (1) Psychiatric Diagnostic Assessment (whether Initial or Continuing Care) is allowed
per State Fiscal Year.
225.000
Diagnosis and Clinical Impression
12-15-14
Diagnosis and clinical impression is required in the terminology of ICD.
226.000
Documentation/Record Keeping Requirements
226.100
Reserved
11-1-09
226.200
Documentation
12-1-12
The RSPMI provider must develop and maintain sufficient written documentation to support each
medical or remedial therapy, service, activity or session for which Medicaid reimbursement is
sought. This documentation, at a minimum, must consist of:
Section II-23
Rehabilitative Services for Persons with Mental Illness
Section II
A.
Must be individualized to the beneficiary and specific to the services provided, duplicated
notes are not allowed.
B.
The date and actual time the services were provided (Time frames may not overlap
between services. All services must be outside the time frame of other services.),
C.
Name and credentials of the person, who provided the services,
D.
The setting in which the services were provided. For all settings other than the provider’s
enrolled sites, the name and physical address of the place of service must be included,
E.
The relationship of the services to the treatment regimen described in the plan of care and
F.
Updates describing the patient’s progress and
G.
For services that require contact with anyone other than the beneficiary, evidence of
conformance with HIPAA regulations, including presence in documentation of Specific
Authorizations, is required.
Documentation must be legible and concise. The name and title of the person providing the
service must reflect the appropriate professional level in accordance with the staffing
requirements found in Section 213.000.
Every individual receiving Rehabilitative Day Services must have both daily notes and a weekly
summary documented in the medical record.
The weekly summary must be signed by a Mental Health Professional (MHP) and include a
description of therapeutic activities provided and the beneficiary’s progress or lack of progress in
achieving the treatment plan goal(s) and established outcomes to be accomplished.
Additionally, if a Mental Health Paraprofessional (MHPP) documents and signs the daily notes,
the supervising MHP must sign the weekly summary. The supervising MHP’s signature indicates
that the MHP has supervised and approves of the daily services provided by the MHPP.
All documentation must be available to representatives of the Division of Medical Services at the
time of an audit by the Medicaid Program Integrity Unit. All documentation must be available at
the provider’s place of business. No more than thirty (30) days will be allowed after the date on
the recoupment notice in which additional documentation will be accepted. Additional
documentation will not be accepted after the 30-day period.
227.000
Medical Necessity
10-4-09
All RSPMI services must be medically necessary.
227.001
Prescription for RSPMI Services
10-4-09
Medicaid will not cover any RSPMI service without a current prescription signed by a psychiatrist
or physician. Prescriptions shall be based on consideration of the RSPMI Assessment and
proposed master treatment plan and an evaluation of the enrolled beneficiary (directly or through
review of the medical records and consultation with the treatment staff). The prescription of the
services will be documented by the psychiatrist’s or physician’s written approval of the RSPMI
master treatment plan. Subsequent revisions of the patient’s RSPMI master treatment plan will
also be documented by the psychiatrist’s or physician’s written approval in the enrolled
beneficiary’s medical record. Approval of all updates or revisions to the Master treatment plan
must be documented within 14 calendar days by the physician’s dated signature on the revised
document.
227.100
Prescription for Speech Therapy
10-4-09
Section II-24
Rehabilitative Services for Persons with Mental Illness
Section II
Speech therapy services are available to Medicaid-eligible beneficiaries. Providers of speech
therapy services are required to have a physician prescription for services in each patient’s
record.
A written prescription is required for speech therapy services, signed and dated by the PCP or
the attending physician. Form DMS-640 is required for the prescription. The form must be in the
patient’s record. View or print form DMS-640.
A.
The beneficiary’s PCP or attending physician must sign the prescription.
B.
A prescription for speech therapy services is valid for 1 year unless the prescribing
physician specifies a shorter period of time.
227.110
Procedures for Obtaining Extension of Benefits for Speech Therapy
11-1-05
Requests for extension of benefits for speech therapy services for beneficiaries under age 21
must be mailed to the Arkansas Foundation for Medical Care, Inc. (AFMC). View or print
Arkansas Foundation for Medical Care, Inc., contact information. A request for extension of
benefits must meet the medical necessity requirement, and adequate documentation must be
provided to support this request.
A.
Requests for extension of benefits are considered only after a claim is denied because the
patient’s benefit limits are exhausted.
B.
The request for extension of benefits must be received by AFMC within 90 calendar days
of the date of the benefits-exhausted denial.
C.
1.
Submit with the request a copy of the Medical Assistance Remittance and Status
Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
2.
AFMC will not accept extension of benefits requests sent via electronic facsimile
(FAX).
Form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory, and
X-Ray Services, must be utilized for requests for extension of benefits for therapy services.
View or print form DMS-671. Consideration of requests for extension of benefits requires
correct completion of all fields on this form. The instructions for completion of this form are
located on the back of the form. The provider’s signature (with his or her credentials) and
the date of the request are required on the form. Stamped or electronic signatures are
accepted. All applicable records that support the medical necessity of the extended
benefits request should be attached.
AFMC will approve or deny an extension of benefits request, or request additional
information, within 30 calendar days of their receiving the request. AFMC reviewers will
simultaneously advise the provider and the beneficiary when a request is denied.
227.111
Reconsideration of Extension of Benefits Denial
11-1-05
Any reconsideration request for denial of extension of benefits must be received at AFMC within
thirty (30) days from the next business day following the postmark date on the envelope
containing this denial letter. When requesting reconsideration of a denial, the following
information is required:
A.
Return a copy of the current NOTICE OF ACTION denial letter with re-submissions.
B.
Return all previously submitted documentation as well as additional information for
reconsideration.
Only one reconsideration is allowed. Any reconsideration request that does not include the
required documentation will be automatically denied.
Section II-25
Rehabilitative Services for Persons with Mental Illness
Section II
AFMC reserves the right to request further clinical documentation as deemed necessary to
complete the medical review.
227.112
Appealing an Adverse Action
11-1-05
When the state Medicaid agency or its designee denies a benefit extension request, the
beneficiary and/or the provider may appeal the denial and request a fair hearing.
An appeal request must be in writing and must be received by the Appeals and Hearings Section
of the Department of Human Services (DHS) within thirty (30) days from the next business day
following the postmark date on the envelope containing the denial letter. View or print the
Department of Human Services, Appeals and Hearings Section contact information.
228.000
Provider Reviews
11-1-04
The Utilization Review Section of the Arkansas Division of Medical Services has the
responsibility for assuring quality medical care for its beneficiaries, along with protecting the
integrity of both state and federal funds supporting the Medical Assistance Program.
228.100
Reserved
11-1-09
228.200
Reserved
11-1-09
228.300
Record Reviews
12-1-13
The Division of Medical Services (DMS) of the Arkansas Department of Human Services (DHS)
has contracted with ValueOptions® to perform on-site inspections of care (IOC) and retrospective
reviews of outpatient mental health services provided by RSPMI providers. View or print
ValueOptions contact information. The reviews are conducted by licensed mental health
professionals and are based on applicable federal and state laws, rules and professionally
recognized standards of care.
228.310
On-Site Inspections of Care (IOC)
228.311
Purpose of the Review
12-1-13
The on-site inspections of care of RSPMI providers are intended to:
A.
Promote RSPMI services being provided in compliance with federal and state laws, rules
and professionally recognized standards of care;
B.
Identify and clearly define areas of deficiency where the provision of services is not in
compliance with federal and state laws, rules and professionally recognized standards of
care;
C.
Require provider facilities to develop and implement appropriate corrective action plans to
remediate all deficiencies identified;
D.
Provide accountability that corrective action plans are implemented and
E.
Determine the effectiveness of implemented corrective action plans.
The review tool, process and procedures are available on the contractor’s website at
http://arkansas.valueoptions.com/provider/prv_forms.htm. Any amendments to the review
tool will be adopted under the Arkansas Administrative Procedures Act.
228.312
Provider Notification of IOC
11-1-04
Section II-26
Rehabilitative Services for Persons with Mental Illness
Section II
The provider will be notified no more than 48 hours before the scheduled arrival of the inspection
team. It is the responsibility of the provider to provide a reasonably comfortable place for the
team to work. When possible, this location will provide reasonable access to the patient care
areas and the medical records.
228.313
Information Available Upon Arrival of the IOC Team
12-1-13
The provider shall make the following available upon the IOC Team’s arrival at the site:
A.
Medical records of Arkansas Medicaid beneficiaries who are identified by the reviewer;
B.
One or more knowledgeable administrative staff member(s) to assist the team;
C.
The opportunity to assess direct patient care in a manner least disruptive to the actual
provision of care;
D.
Staff personnel records, complete with hire dates, dates of credentialing and copies of
current licenses, credentials, criminal background checks and similar or related records;
E.
Written policies, procedures and quality assurance committee minutes;
F.
Clinical Administration, Clinical Services, Quality Assurance, Quality improvement,
Utilization Review and Credentialing;
G.
Program descriptions, manuals, schedules, staffing plans and evaluation studies;
H.
YOQ documentation and
I.
If identified as necessary and as requested, additional documents required by a provider’s
individual licensing board, child maltreatment checks and adult maltreatment checks.
228.314
Cases Chosen for Review
12-1-13
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:
228.315
1.
All required assessments, including SED/SMI Certifications where applicable;
2.
Master treatment plan and periodic reviews of master treatment plan;
3.
Progress notes, including physician notes;
4.
Physician orders and lab results and
5.
Copies of records. The reviewer shall retain a copy of any record reviewed.
Program Activity Observation
11-1-04
The reviewer will observe at least one program activity.
228.316
Beneficiary/Family Interviews
12-1-13
The provider is required to arrange interviews of Medicaid beneficiaries and family members as
requested by the IOC team, preferably with the beneficiaries whose records are selected for
review. If a beneficiary whose records are chosen for review is not available, then the interviews
shall be conducted with a beneficiary on-site whose records are not scheduled for review.
Beneficiaries and family members may be interviewed on-site, by telephone conference or both.
Section II-27
Rehabilitative Services for Persons with Mental Illness
228.317
Exit Conference
Section II
11-1-04
The Inspection of Care Team will conduct an exit conference summarizing their findings and
recommendations. Providers are free to involve staff in the exit conference.
228.318
Written Reports and Follow-Up Procedures
12-1-13
The contractor shall provide a written report of the IOC team’s findings to the provider, DMS
Behavioral Health Unit and Arkansas Office of Medicaid Inspector General within 14 calendar
days from the last day of on-site inspection. The written report shall clearly identify any area of
deficiency and required submission of a corrective action plan.
The contractor shall provide a notification of either acceptance or requirement of directed
correction to the provider, DMS Behavioral Health Unit and Arkansas Office of Medicaid
Inspector General within 30 calendar days of receiving a proposed corrective action plan and
shall monitor corrective actions to ensure the plan is implemented and results in compliance.
All IOC reviews are subject to policy regarding Administrative Remedies and Sanctions (Section
150.000), Administrative Reconsideration and Appeals (Section 160.000) and Provider Due
Process (Section 190.000). DMS will not voluntarily publish the results of the IOC review until
the provider has exhausted all administrative remedies. Administrative remedies are exhausted
if the provider does not seek a review or appeal within the time period permitted by law or rule.
228.320
DMS/DBHS Work Group Reports and Recommendations
12-1-13
The DMS/DBHS Work Group (comprised of representatives from the Behavioral Health Unit, the
Arkansas Office of Medicaid Inspector General, the Division of Behavioral Health Services, the
Office of Quality Assurance, the utilization review agency, as well as other units or divisions as
required) will meet monthly to discuss IOC reports. When warranted by IOC results, the
DMS/DBHS Work Group shall recommend to the DHS Review Team one or more actions in
Section 228.322. Recommendations shall be in writing and shall include supporting
documentation.
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).
228.321
Corrective Action Plans
12-1-13
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 Behavioral Health Services.
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.
228.322
Actions
12-1-13
Actions that may be taken following an inspection of care review include, but are not limited to:
A.
Decertification of any beneficiary determined to not meet medical necessity criteria for
outpatient mental health services;
Section II-28
Rehabilitative Services for Persons with Mental Illness
Section II
B.
Decertification of any provider determined to be noncompliant with the Division of
Behavioral Health Services 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/DBHS
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 or
M. Any sanction identified in Section 152.000.
228.330
Retrospective Reviews
1-15-12
The Division of Medical Services (DMS) of the Arkansas Department of Human Services has
contracted with a Quality Improvement Organization (QIO) or QIO-like organization to perform
retrospective (post payment) reviews of outpatient mental health services provided by RSPMI
providers. View or print ValueOptions contact information.
The reviews will be conducted by licensed mental health professionals who will examine the
medical record for compliance with federal and state laws and regulations.
228.331
Purpose of the Review
1-15-12
The purpose of the review is to:
A.
Ensure that services are delivered in accordance with the plan of care and conform to
generally accepted professional standards.
B.
Evaluate the medical necessity of services provided to Medicaid beneficiaries.
C.
Evaluate the clinical documentation to determine if it is sufficient to support the services
billed during the requested period of authorized services.
D.
Safeguard the Arkansas Medicaid program against unnecessary or inappropriate use of
services and excess payments in compliance with 42 CFR § 456.3(a).
Section II-29
Rehabilitative Services for Persons with Mental Illness
228.332
Review Sample and the Record Request
Section II
1-15-12
On a calendar quarterly basis, the contractor will select a statistically valid random sample from
an electronic data set of all RSPMI beneficiaries whose dates of service occurred during the
three-month selection period. If a beneficiary 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 ProviderConnect. View
or print ValueOptions contact information. When faxing or mailing records, send them to the
attention of “Retrospective Review Process.” Records will not be accepted via email.
228.333
Review Process
1-15-12
The record will be reviewed using a review tool based upon the promulgated Medicaid RSPMI
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 nursing
or therapy (LCSW, LMSW, LPE, LPC, RN, 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.
228.334
Reserved
1-15-12
Section II-30
Rehabilitative Services for Persons with Mental Illness
Section II
228.335
Reserved
1-15-12
228.400
Retrospective Review of Speech Therapy Services for Individuals
Under Age 21
11-1-05
Retrospective review of speech therapy services is required for beneficiaries under age 21. The
purpose of retrospective review is promotion of effective, efficient and economical delivery of
health care services.
The Quality Improvement Organization (QIO), Arkansas Foundation for Medical Care, Inc.
(AFMC), under contract to the Arkansas Medicaid Program, performs retrospective reviews by
reviewing medical records to determine if services delivered and reimbursed by Medicaid meet
medical necessity requirements. View or print Arkansas Foundation for Medical Care, Inc.,
contact information.
Specific guidelines have been developed for speech therapy retrospective reviews. These
guidelines may be found in the following policy sections.
228.410
A.
Speech-Language Therapy Guidelines for Retrospective Review
11-1-10
Medical Necessity
Speech-language therapy services must be medically necessary for the treatment of the
individual’s illness or injury. A diagnosis alone is not sufficient documentation to support
the medical necessity of therapy. To be considered medically necessary, the following
conditions must be met:
B.
1.
The services must be considered under accepted standards of practice to be a
specific and effective treatment for the patient’s condition.
2.
The services must be of such a level of complexity or the patient’s condition must be
such that the services required can be safely and effectively performed only by or
under the supervision of a qualified speech and language pathologist.
3.
There must be a reasonable expectation that therapy will result in meaningful
improvement or a reasonable expectation that therapy will prevent a worsening of the
condition. (See the medical necessity definition in the Glossary of this manual.)
Types of Communication Disorders
1.
Language Disorders — Impaired comprehension and/or use of spoken, written
and/or other symbol systems. This disorder may involve the following components:
forms of language (phonology, morphology, syntax), content and meaning of
language (semantics, prosody), function of language (pragmatics) and/or the
perception/processing of language. Language disorders may involve one, all or a
combination of the above components.
2.
Speech Production Disorders — Impairment of the articulation of speech sounds,
voice and/or fluency. Speech Production disorders may involve one, all or
combination of these components of the speech production system.
An articulation disorder may manifest as an individual sound deficiency, i.e.,
traditional articulation disorder, incomplete or deviant use of the phonological system,
i.e. phonological disorder, or poor coordination of the oral-motor mechanism for
purposes of speech production, i.e. verbal and/or oral apraxia, dysarthria.
3.
Oral Motor/Swallowing/Feeding Disorders — Impairment of the muscles, structures
and/or functions of the mouth (physiological or sensory-based) involved with the
entire act of deglutition from placement and manipulation of food in the mouth
through the oral and pharyngeal phases of the swallow. These disorders may or
may not result in deficits to speech production.
Section II-31
Rehabilitative Services for Persons with Mental Illness
C.
Section II
Evaluation and Report Components
1.
STANDARDIZED SCORING KEY:
Mild: Scores between 84-78; -1.0 standard deviation
Moderate: Scores between 77-71; -1.5 standard deviations
Severe: Scores between 70-64; -2.0 standard deviations
Profound: Scores of 63 or lower; -2.0+ standard deviations
2.
LANGUAGE: To establish medical necessity, results from a comprehensive
assessment in the suspected area of deficit must be reported. (Refer to Section
228.410, part D, paragraphs 9-12 for required frequency of re-evaluations.) A
comprehensive assessment for Language disorder must include:
a.
Date of evaluation.
b.
Child’s name and date of birth.
c.
Diagnosis specific to therapy.
d.
Background information including pertinent medical history; and, if the child is
12 months of age or younger, gestational age. The child should be tested in
the child’s dominant language; if not, an explanation must be provided in the
evaluation.
NOTE: To calculate a child’s gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological
age. Therefore, a 7-month-old, former 28 week gestational age
infant has a corrected age of 4 months according to the following
equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
3.
e.
Results from an assessment specific to the suspected type of language
disorder, including all relevant scores, quotients and/or indexes, if applicable.
A comprehensive measure of language must be included for initial evaluations.
Use of one-word vocabulary tests alone will not be accepted. (Review Section
228.414 — Accepted Tests for Speech-Language Therapy.)
f.
If applicable, test results should be adjusted for prematurity (less than 37
weeks gestation) if the child is 12 months of age or younger, and this should be
noted in the evaluation.
g.
Oral-peripheral speech mechanism examination, which includes a description
of the structure and function of the orofacial structures.
h.
Formal or informal assessment of hearing, articulation, voice and fluency skills.
i.
An interpretation of the results of the evaluation including recommendations for
frequency and intensity of treatment.
j.
A description of functional strengths and limitations, a suggested treatment
plan and potential goals to address each identified problem.
k.
Signature and credentials of the therapist performing the evaluation.
SPEECH PRODUCTION (Articulation, Phonological, Apraxia): To establish medical
necessity, results from a comprehensive assessment in the suspected area of deficit
must be reported. (Refer to Section 228.410, part D, paragraphs 9-12 for required
frequency of re-evaluations.) A comprehensive assessment for Speech Production
(Articulation, Phonological, Apraxia) disorder must include:
Section II-32
Rehabilitative Services for Persons with Mental Illness
Section II
a.
Date of evaluation.
b.
Child’s name and date of birth.
c.
Diagnosis specific to therapy.
d.
Background information including pertinent medical history; and, if the child is
12 months of age or younger, gestational age. The child should be tested in
the child’s dominant language; if not, an explanation must be provided in the
evaluation.
NOTE: To calculate a child’s gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological
age. Therefore, a 7-month-old, former 28 week gestational age
infant has a corrected age of 4 months according to the following
equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
4.
e.
Results from an assessment specific to the suspected type of speech
production disorder, including all relevant scores, quotients and/or indexes, if
applicable. All errors specific to the type of speech production disorder must
be reported (e.g., positions, processes, motor patterns). (Review Section
228.414 — Accepted Tests for Speech-Language Therapy.)
f.
If applicable, test results should be adjusted for prematurity (less than 37
weeks gestation) if the child is 12 months of age or younger, and this should be
noted in the evaluation.
g.
Oral-peripheral speech mechanism examination, which includes a description
of the structure and function of orofacial structures.
h.
Formal screening of language skills. Examples include, but are not limited to,
the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.
i.
Formal or informal assessment of hearing, voice and fluency skills.
j.
An interpretation of the results of the evaluation including recommendations for
frequency and intensity of treatment.
k.
A description of functional strengths and limitations, a suggested treatment
plan and potential goals to address each identified problem.
l.
Signature and credentials of the therapist performing the evaluation.
SPEECH PRODUCTION (Voice): To establish medical necessity, results from a
comprehensive assessment in the suspected area of deficit must be reported. (Refer
to Section 228.410, part D, paragraphs 9-12 for required frequency of reevaluations.) A comprehensive assessment for Speech Production (Voice) disorder
must include:
a.
A medical evaluation to determine the presence or absence of a physical
etiology is a prerequisite for evaluation of voice disorder.
b.
Date of evaluation.
c.
Child’s name and date of birth.
d.
Diagnosis specific to therapy.
e.
Background information including pertinent medical history; and, if the child is
12 months of age or younger, gestational age. The child should be tested in
the child’s dominant language; if not, an explanation must be provided in the
evaluation.
Section II-33
Rehabilitative Services for Persons with Mental Illness
Section II
NOTE: To calculate a child’s gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological
age. Therefore, a 7-month-old, former 28 week gestational age
infant has a corrected age of 4 months according to the following
equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
5.
f.
Results from an assessment relevant to the suspected type of speech
production disorder, including all relevant scores, quotients and/or indexes, if
applicable. (Review Section 228.414 — Accepted Tests for Speech-Language
Therapy.)
g.
If applicable, test results should be adjusted for prematurity (less than 37
weeks gestation) if the child is 12 months of age or younger, and this should be
noted in the evaluation.
h.
Oral-peripheral speech mechanism examination, which includes a description
of the structure and function of orofacial structures.
i.
Formal screening of language skills. Examples include, but are not limited to,
the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.
j.
Formal or informal assessment of hearing, articulation and fluency skills.
k.
An interpretation of the results of the evaluation including recommendations for
frequency and intensity of treatment.
l.
A description of functional strengths and limitations, a suggested treatment
plan and potential goals to address each identified problem.
m.
Signature and credentials of the therapist performing the evaluation.
SPEECH PRODUCTION (Fluency): To establish medical necessity, results from a
comprehensive assessment in the suspected area of deficit must be reported. (Refer
to Section 228.410, part D, paragraphs 9-12 for required frequency of reevaluations.) A comprehensive assessment for Speech Production (Fluency)
disorder must include:
a.
Date of evaluation.
b.
Child’s name and date of birth.
c.
Diagnosis specific to therapy.
d.
Background information including pertinent medical history; and, if the child is
12 months of age or younger, gestational age. The child should be tested in
the child’s dominant language; if not, an explanation must be provided in the
evaluation.
NOTE: To calculate a child’s gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological
age. Therefore, a 7-month-old, former 28 week gestational age
infant has a corrected age of 4 months according to the following
equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
Section II-34
Rehabilitative Services for Persons with Mental Illness
Section II
4 months
6.
e.
Results from an assessment specific to the suspected type of speech
production disorder, including all relevant scores, quotients and/or indexes, if
applicable. (Review Section 228.414 — Accepted Tests for Speech-Language
Therapy.)
f.
If applicable, test results should be adjusted for prematurity (less than 37
weeks gestation) if the child is 12 months of age or younger, and this should be
noted in the evaluation.
g.
Oral-peripheral speech mechanism examination, which includes a description
of the structure and function of orofacial structures.
h.
Formal screening of language skills. Examples include, but are not limited to,
the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.
i.
Formal or informal assessment of hearing, articulation and voice skills.
j.
An interpretation of the results of the evaluation including recommendations for
frequency and intensity of treatment.
k.
A description of functional strengths and limitations, a suggested treatment
plan and potential goals to address each identified problem.
l.
Signature and credentials of the therapist performing the evaluation.
ORAL MOTOR/SWALLOWING/FEEDING: To establish medical necessity, results
from a comprehensive assessment in the suspected area of deficit must be reported.
(Refer to Section 228.410, part D, paragraphs 9-12 for required frequency of reevaluations.) A comprehensive assessment for Oral Motor/Swallowing/Feeding
disorder must include:
a.
Date of evaluation.
b.
Child’s name and date of birth.
c.
Diagnosis specific to therapy.
d.
Background information including pertinent medical history; and, if the child is
12 months of age or younger, gestational age. The child should be tested in
the child’s dominant language; if not, an explanation must be provided in the
evaluation.
NOTE: To calculate a child’s gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological
age. Therefore, a 7-month-old, former 28 week gestational age
infant has a corrected age of 4 months according to the following
equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
e.
Results from an assessment specific to the suspected type of oral
motor/swallowing/feeding disorder, including all relevant scores, quotients
and/or indexes, if applicable. (Review Section 228.414 — Accepted Tests for
Speech-Language Therapy.)
f.
If swallowing problems and/or signs of aspiration are noted, then include a
statement indicating that a referral for a videofluoroscopic swallow study has
been made.
g.
If applicable, test results should be adjusted for prematurity (less than 37
weeks gestation) if the child is 12 months of age or younger, and this should be
Section II-35
Rehabilitative Services for Persons with Mental Illness
Section II
noted in the evaluation.
D.
h.
Formal or informal assessment of hearing, language, articulation, voice and
fluency skills.
i.
An interpretation of the results of the evaluation including recommendations for
frequency and intensity of treatment.
j.
A description of functional strengths and limitations, a suggested treatment
plan and potential goals to address each identified problem.
k.
Signature and credentials of the therapist performing the evaluation.
Interpretation and Eligibility: Ages Birth to 21
1.
2.
LANGUAGE: Two language composite or quotient scores (i.e., normed or
standalone) in the area of suspected deficit must be reported, with at least one being
a norm-referenced, standardized test with good reliability and validity. (Use of two
one-word vocabulary tests alone will not be accepted.)
a.
For children age birth to three: criterion-referenced tests will be accepted as a
second measure for determining eligibility for language therapy.
b.
For children age three to 21, criterion-referenced tests will not be accepted as a
second measure when determining eligibility for language therapy. (When use
of standardized instruments is not appropriate, see Section 228.410, part D,
paragraph 8).
c.
Age birth to three: Eligibility for language therapy will be based upon a
composite or quotient score that is -1.5 standard deviations (SD) below the
mean or greater from a norm-referenced, standardized test, with corroborating
data from a criterion-referenced measure. When these two measures do not
agree, results from a third measure that corroborate the identified deficits are
required to support the medical necessity of services.
d.
Age three to 21: Eligibility for language therapy will be based upon 2
composite or quotient scores that are -1.5 standard deviations (SD) below the
mean or greater. When -1.5 SD or greater is not indicated by both of these
scores, a third standardized score indicating a -1.5 SD or greater is required to
support the medical necessity of services.
ARTICULATION AND/OR PHONOLOGY: Two tests and/or procedures must be
administered, with at least one being from a norm-referenced, standardized test with
good reliability and validity.
Eligibility for articulation and/or phonological therapy will be based upon standard
scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or
greater is not indicated by both of these tests, corroborating data from accepted
procedures can be used to support the medical necessity of services (review Section
228.414 — Accepted Tests for Speech-Language Therapy).
3.
APRAXIA: Two tests and/or procedures must be administered, with at least one
being a norm-referenced, standardized test with good reliability and validity.
Eligibility for apraxia therapy will be based upon standard scores (SS) of -1.5 SD or
greater below the mean from two tests. When -1.5 SD or greater is not indicated by
both of these tests, corroborating data from a criterion-referenced test and/or
accepted procedures can be used to support the medical necessity of services
(review Section 228.414 — Accepted Tests for Speech-Language Therapy).
4.
VOICE: Due to the high incidence of medical factors that contribute to voice
deviations, a medical evaluation is a requirement for eligibility for voice therapy.
Eligibility for voice therapy will be based upon a medical referral for therapy and a
functional profile of voice parameters that indicates a moderate or severe
deficit/disorder.
Section II-36
Rehabilitative Services for Persons with Mental Illness
5.
Section II
FLUENCY: At least one norm-referenced, standardized test with good reliability and
validity and at least one supplemental tool to address affective components.
Eligibility for fluency therapy will be based upon an SS of -1.5 SD below the mean or
greater on the standardized test.
6.
ORAL MOTOR/SWALLOWING/FEEDING: An in-depth, functional profile of oral
motor structures and function.
Eligibility for oral-motor/swallowing/feeding therapy will be based upon an in-depth
functional profile of oral motor structures and function using a thorough protocol (e.g.,
checklist, profile) that indicates a moderate or severe deficit or disorder. When
moderate or severe aspiration has been confirmed by videofluoroscopic swallow
study, the patient can be treated for feeding difficulties via the recommendations set
forth in the swallow study report.
7.
All subtests, components and scores must be reported for all tests used for eligibility
purposes.
8.
When administration of standardized, norm-referenced instruments is inappropriate,
the provider must submit an in-depth functional profile of the child’s communication
abilities. An in-depth functional profile is a detailed narrative or description of a
child’s communication behaviors that specifically explains and justifies the following:
a.
The reason standardized testing is inappropriate for this child,
b.
The communication impairment, including specific skills and deficits, and
c.
The medical necessity of therapy.
d.
Supplemental instruments from Accepted Tests for Speech-Language Therapy
may be useful in developing an in-depth functional profile.
9.
Children (age birth to age 21) receiving services outside of the schools must be
evaluated annually.
10.
Children (age birth to 24 months) in the Child Health Management Services (CHMS)
Program must be evaluated every 6 months.
11.
Children (age three to 21) receiving services within schools as part of an Individual
Program Plan (IPP) or an Individual Education Plan (IEP) must have a full evaluation
every three years; however, an annual update of progress is required.
12.
Children (age three to 21) receiving privately contracted services, apart from or in
addition to those within the schools, must have a full evaluation annually.
13.
IQ scores are required for all children who are school age and receiving language
therapy. Exception: IQ scores are not required for children under ten (10) years of
age.
228.411
Reserved
11-1-10
228.412
Reserved
11-1-10
228.413
Reserved
11-1-10
228.414
Accepted Tests for Speech-Language Therapy
3-15-12
To view a current list of accepted tests for Speech-Language Therapy, refer to Section 214.410
of the Occupational, Physical, Speech Therapy Services manual.
228.415
Intelligence Quotient (IQ) Testing
11-1-10
Children receiving language intervention therapy must have cognitive testing once they reach
ten (10) years of age. This also applies to home-schooled children. If the IQ score is higher
Section II-37
Rehabilitative Services for Persons with Mental Illness
Section II
than the qualifying language scores, the child qualifies for language therapy; if the IQ score is
lower than the qualifying language test scores, the child would appear to be functioning at or
above the expected level. In this case, the child may be denied for language therapy. If a
provider determines that therapy is warranted, an in-depth functional profile must be
documented. However, IQ scores are not required for children under ten (10) years of age.
A.
IQ Tests — Traditional
Test
Abbreviation
Stanford-Binet
S-B
The Wechsler Preschool & Primary Scales of Intelligence, Revised
WPPSI-R
Slosson
B.
228.416
Wechsler Intelligence Scale for Children, Third Edition
WISC-III
Kauffman Adolescent & Adult Intelligence Test
KAIT
Wechsler Adult Intelligence Scale, Third Edition
WAIS-III
Differential Ability Scales
DAS
Reynolds Intellectual Assessment Scales
RIAS
Severe and Profound IQ Tests/Non-Traditional — Supplemental — Norm-Reference
Test
Abbreviation
Comprehensive Test of Nonverbal Intelligence
CTONI
Test of Nonverbal Intelligence — 1997
TONI-3
Functional Linguistic Communication Inventory
FLCI
Recoupment Process
11-1-05
The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate
the recoupment process for all claims that AFMC, the state Quality Improvement Organization
(QIO), has denied because the records submitted do not support the claim of medical necessity.
Arkansas Medicaid will send the provider an Explanation of Recoupment Notice that will include
the claim date of service, Medicaid beneficiary name and ID number, service provided, amount
paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.
229.000
Medicaid Beneficiary Appeal Process
10-13-03
When an adverse decision is received, the beneficiary may request a fair hearing of the denial
decision.
The appeal request must be in writing and received by the Appeals and Hearings Section of the
Department of Human Services within thirty days of the date on the letter explaining the denial of
services. View or print the Appeals and Hearings Section contact information.
229.100
Electronic Signatures
10-8-10
Medicaid will accept electronic signatures provided the electronic signatures comply with
Arkansas Code § 25-31-103 et seq.
Section II-38
Rehabilitative Services for Persons with Mental Illness
230.000
PRIOR AUTHORIZATION (PA) AND EXTENSION OF
BENEFITS
231.000
Introduction to Prior Authorization and Extension of Benefits
Section II
4-1-14
The Division of Medical Services contracts with ValueOptions to complete the prior authorization
and extension of benefit processes.
231.001
Prior Authorization Request for Telemedicine
4-1-14
When a provider requests PA for services to be provided via telemedicine, the procedure codes
and modifiers (if any) listed in Section 231.100 must be shown on the claim form; “telemedicine”
must be specified on the request.
231.002
Prior Authorization Request for Foster Child
4-1-14
A request for prior authorization for services to be provided to a foster child must specify that the
request is for a foster child. A request for services to be provided to a child in the custody of the
Division of Youth Services (DYS) must specify DYS custody.
231.003
Request for Beneficiary Released to DHS Care under Arkansas
Code Annotated § 5-2-315
4-1-14
A prior authorization, extension of benefits and retroactive request for services to be provided to
a beneficiary released to DHS care under Arkansas Code Annotated § 5-2-315 must:
A.
State that the request is for a beneficiary released to DHS care;
B.
Include or attach the prescribed regimen of medical, psychiatric or psychological care or
treatment that has been:
1.
Prepared for the person acquitted;
2.
Certified to the circuit court as appropriate by the director of the facility in which the
person acquitted is committed; and
3.
Found by the circuit court to be appropriate.
Requests for continuing care authorizations must include copies of the compliance monitor’s
periodic compliance documentation including, without limitation, any written notice(s) of the
acquitee’s failure to comply with the prescribed regimen of medical, psychiatric or psychological
care or treatment and compliance documentation regarding:
A.
Medication;
B.
Treatment and therapy;
C.
Substance abuse treatment; and
D.
Drug testing.
231.100
Prior Authorization and Extension of Benefits
9-1-13
Prior Authorization is required for certain services provided to Medicaid-eligible individuals.
Extension of benefits is required for all other services when the maximum benefit for the service
is exhausted. Yearly service benefits are based on the state fiscal year running from July 1 to
June 30. Extension of Benefits is also required whenever a beneficiary exceeds eight hours of
outpatient services in one 24-hour day, with the exception of crisis intervention, crisis
stabilization intervention by a mental health professional, and crisis stabilization intervention by
paraprofessional.
Section II-39
Rehabilitative Services for Persons with Mental Illness
Section II
Prior authorization and extension requests must be sent to ValueOptions for beneficiaries under
the age of 21. View or print ValueOptions contact information. Information related to clinical
management guidelines and authorization request processes is available at
www.valueoptions.com.
Prior authorization and extension requests must be sent to ValueOptions for beneficiaries age 21
and over. View or print ValueOptions contact information. Information related to clinical
management guidelines and authorization request processes is available at
www.valueoptions.com.
Procedure codes requiring prior authorization:
National Codes
Required Modifier
Service Title
90846
90846
90846
HA, U3,
—
U7 (telemedicine )
Marital/Family Therapy without
patient present
90853
90853
HA, U1
—
Group Outpatient – Group
Psychotherapy
H0034
HA, HQ
Group Outpatient –
Pharmacologic Management by
Physician
H2012
H2012
HA
UA
Therapeutic Day/Acute Day
Treatment
90887
90887
HA
U7 (telemedicine)
Collateral Intervention, MHP
90887
HA, UB
Collateral Intervention, MHPP
H2015
H2015
HA, U5
U6
Intervention, MHP
H2015
U7 (telemedicine)
H2015
H2015
HA, U1
U2
Intervention, MHPP
H2017
H2017
HA, U1
—
Rehabilitative Day Service
Procedure codes requiring Extension of Benefits:
National Codes
Required Modifier
Service Title
Yearly Maximum
90791
90791
HA, U1
U7 (telemedicine)
Mental Health
Evaluation/Diagnosis
16
96101
HA, UA
Psychological Evaluation
32
90885
HA, U2
Master Treatment Plan
8
90887
90887
HA, U2
U3, U7 (telemedicine)
Interpretation of Diagnosis
16
H0004
H0004
H0004
Individual Psychotherapy
48
HA
U7 (telemedicine)
Section II-40
Rehabilitative Services for Persons with Mental Illness
Section II
National Codes
Required Modifier
Service Title
Yearly Maximum
90847
90847
90847
HA, U3
—
U7 (telemedicine)
Marital/Family Therapy
with patient present
48
H2011
H2011
HA
U7 (telemedicine)
Crisis Intervention
72
90792
90792
HA, U1
U7 (telemedicine)
Psychiatric Diagnostic
Assessment
1
90792
90792
HA, U2
U7, U1 (telemedicine)
Psychiatric Diagnostic
Assessment – Continuing
Care
1
99201
99202
99203
99204
99212
99213
99214
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
Physical Examination
12
Pharmacologic
Management
by Physician
12
AND
99201
99202
99203
99204
99212
99213
99214
HA, SA
HA, SA
HA, SA
HA, SA
HA, SA
HA, SA
HA, SA
99212
99212
HA, UB
UB
99213
99213
HA, UB
UB
99214
99214
HA, UB
UB
AND
99212
99212
HA, SA
SA
99213
99213
HA, SA
SA
99214
99214
HA, SA
SA
90885
90885
HA
HA, U1
Pharmacologic
Management by
Psychiatric Mental Health
Clinical Nurse Specialist
or Psychiatric Mental
Health Advanced Nurse
Practitioner
Periodic Review of Master
treatment plan
10
Section II-41
Rehabilitative Services for Persons with Mental Illness
Section II
National Codes
Required Modifier
Service Title
Yearly Maximum
36415
HA
Routine Venipuncture for
Collection of Specimen
12
H2011
H2011
H2011
HA, U6
U2
U2, U7 (telemedicine)
Crisis Stabilization, MHP
72
H2011
H2011
HA, U5
U1
Crisis Stabilization, MHPP
72
240.000
REIMBURSEMENT
10-4-09
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 Medicaid prior to rendering
services.
A.
Outpatient Services
Fifteen-Minute Units
RSPMI services are billed on a per unit basis. A unit of service for an outpatient service is
fifteen (15) minutes unless otherwise stated. Any unit less than five (5) minutes in duration
is not considered a valid length of service and should not be submitted to Medicaid for
payment. To determine how many units should be submitted on the claim, follow these
steps. Begin by totaling the number of minutes of service rendered and divide by fifteen
(15). If the remainder is five (5) or greater, round up to the next highest unit, but if the
remainder is less than five (5), the quotient will be the valid units of service.
Providers may collectively bill for a single date of service but may not collectively bill for
spanning dates of service. For example, an RSPMI service may occur on behalf of a
beneficiary on Monday and then again on Tuesday. The RSPMI provider may bill for the
total amount of time spent on Monday and the total amount of time spent on Tuesday but
may not bill for the total amount of time spent both days as a single date of service. The
maximum allowable for a procedure is the same for all RSPMI providers.
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).
240.010
Fee Schedule
12-1-12
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee
schedule link is located at https://www.medicaid.state.ar.us under the provider manual
section. The fees represent the fee-for-service reimbursement methodology.
Section II-42
Rehabilitative Services for Persons with Mental Illness
Section II
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.
241.000
Rate Appeal Process
10-13-03
A provider may request reconsideration of a Program decision by writing to the Assistant
Director, Division of Medical Services. This request must be received within 20 calendar days
following the application of policy and/or procedure or the notification of the provider of its rate.
Upon receipt of the request for review, the Assistant Director will determine the need for a
Program/Provider conference and will contact the provider to arrange a conference if needed.
Regardless of the Program decision, the provider will be afforded the opportunity for a
conference, if he or she so wishes, for a full explanation of the factors involved and the Program
decision. Following review of the matter, the Assistant Director will notify the provider of the
action to be taken by the Division within 20 calendar days of receipt of the request for review or
the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the
provider may then appeal the question to a standing Rate Review Panel, established by the
Director of the Division of Medical Services, which will include one member of the Division of
Medical Services, a representative of the provider association and a member of the Department
of Human Services (DHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days
following the notification of the initial decision by the Assistant Director, Division of Medical
Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days
after receipt of a request for such appeal. The question(s) will be heard by the panel and a
recommendation will be submitted to the Director of the Division of Medical Services.
250.000
BILLING PROCEDURES
251.000
Introduction to Billing
7-1-07
Rehabilitative Services for Persons with Mental Illness (RSPMI) providers use the CMS-1500
form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid
beneficiaries. Each claim may contain charges for only one beneficiary. View a CMS-1500
sample form.
Section III of this manual contains information about Provider Electronic Solutions (PES) and
other available options for electronic claim submission.
252.000
CMS-1500 Billing Procedures
252.100
Procedure Codes for Types of Covered Services
10-4-09
Covered RSPMI services are outpatient services. Specific RSPMI services are available to
inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine,
and to nursing home and ICF/IID residents. RSPMI services are billed on a per unit basis.
Unless otherwise specified in this manual or the appropriate CPT or HCPCS book, one unit
equals 15 minutes. All services must be provided by at least the minimum staff within the
licensed or certified scope of practice to provide the service.
NOTE: RSPMI providers will continue to use modifiers 22 and 52. Effective for claims
received on or after December 5, 2005, modifier 22 will be replaced with UA and
modifier 52 will be replaced with UB.
Section II-43
Rehabilitative Services for Persons with Mental Illness
252.110
Outpatient Procedure Codes
Section II
8-17-15
(…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description
of the service. When using a procedure code with this symbol, the service must meet the
indicated Arkansas Medicaid description.
National
Code
Required
Modifier
92521
HA, UA
Definition
(Diagnosis: Evaluation of Speech Fluency (e.g., stuttering,
cluttering))
1 unit = 30 minutes
MAXIMUM UNITS PER DAY: 4
MAXIMUM UNITS PER STATE FISCAL YEAR: 4 units
92522
HA, UA
(Diagnosis: Evaluation of Speech Sound Production (e.g.,
articulation, phonological process, apraxia, dysarthria))
1 unit = 30 minutes
MAXIMUM UNITS PER DAY: 4
MAXIMUM UNITS PER STATE FISCAL YEAR: 4 units
92523
HA, UA
(Diagnosis: Evaluation of Speech Production (e.g., articulation,
phonological process, apraxia, dysarthria) with evaluation of
language comprehension and expression (e.g., receptive and
expressive language))
1 unit = 30 minutes
MAXIMUM UNITS PER DAY: 4
MAXIMUM UNITS PER STATE FISCAL YEAR: 4 units
92524
HA, UA
(Diagnosis: Behavioral and qualitative analysis of voice and
resonance)
1 unit = 30 minutes
MAXIMUM UNITS PER DAY: 4
MAXIMUM UNITS PER STATE FISCAL YEAR: 4 units
90791
HA, U1
SERVICE: Mental Health Evaluation/Diagnosis (Formerly known
only as Diagnosis)
DEFINITION: The cultural, developmental, age and disability-relevant
clinical evaluation and determination of a beneficiary's mental status,
functioning in various life domains; and an axis five DSM diagnostic
formulation for the purpose of developing a plan of care. This service
is required prior to provision of all other mental health services with the
exception of crisis interventions. Services are to be congruent with the
age, strengths necessary, accommodations for disability and cultural
framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 16
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); Nursing Facility (32); Skilled Nursing Facility (31); School
(03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
Section II-44
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
(14); ICF/IID (54)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

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 to include all five axes

Treatment recommendations

Staff signature/credentials/date of signature
NOTES and COMMENTS: 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., Prior
Authorization requests, master treatment plans, etc.).
90791
U7
Mental Health Evaluation/Diagnosis: Use the above definition and
requirements.
ADDITIONAL INFORMATION: Use code 90791 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
96101
HA, UA
SERVICE: Psychological Evaluation (Formerly Diagnosis –
Psychological Test/Evaluation and Diagnosis – Psychological
Testing Battery)
DEFINITION: A Psychological Evaluation employs standardized
psychological tests conducted and documented for evaluation,
diagnostic or therapeutic purposes. The evaluation must be medically
necessary, culturally relevant, with reasonable accommodations for any
disability, provide information relevant to the beneficiary’s continuation
in treatment and assist in treatment planning. All psychometric
instruments must be administered, scored and interpreted by the
qualified professional.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 16
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 32
Section II-45
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
ALLOWABLE PLACES OF SERVICE: Office (11)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop times of actual encounter with beneficiary

Start and stop times of scoring, interpretation and report
preparation

Place of service

Identifying information

Rationale for referral

Presenting problem(s)

Culturally- and age-appropriate psychosocial history and
assessment

Mental status/clinical observations and impressions

Psychological tests used, results and interpretations, as
indicated

Axis Five DSM diagnostic impressions

Treatment recommendations and findings related to rationale
for service and guided by the master treatment plan and test
results

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: Medical necessity for this service is met
when the service is necessary to establish a differential diagnosis of
behavioral or psychiatric conditions, when the history and
symptomatology are not readily attributable to a particular psychiatric
diagnosis and the questions to be answered by the evaluation could
not be resolved by a psychiatric/diagnostic interview, observation in
therapy or an assessment for level of care at a mental health facility,
Or
Medical necessity is met when the beneficiary has demonstrated a
complexity of issues related to cognitive functioning or the impact of a
disability on a condition or behavior and the service is necessary to
develop treatment recommendations after the beneficiary has received
various treatment services and modalities, has not progressed in
treatment and continues to be symptomatic.
Medicaid WILL NOT reimburse evaluations or testing that is considered
primarily educational. Such services are those used to identify specific
learning disabilities and developmental disabilities in beneficiaries who
have no presenting behavioral or psychiatric symptoms which meet the
need for mental health treatment evaluation. This type of evaluation
and testing is provided by local school systems under applicable state
and federal laws and rules. Psychological Evaluation services that are
ordered strictly as a result of court-ordered services are not covered
unless medical necessity criteria are met. Psychological Evaluation
Section II-46
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
90792
HA, U1
Section II
Definition
services for employment, disability qualification or legal/court-related
purposes are not reimbursable by Medicaid as they are not considered
treatment of illness. A Psychological Evaluation report must be
completed within fourteen (14) calendar days of the examination,
documented, clearly identified as such and signed/dated by the staff
completing the evaluation. This service constitutes both face-to-face
time administering tests to the beneficiary and time interpreting these
test results and preparing the report.
SERVICE: Psychiatric Diagnostic Assessment – Initial
DEFINITION: A direct face-to-face service contact occurring between
the physician or the Adult Psychiatric Mental Health Advanced Nurse
Practitioner/Family Psychiatric Mental Health Advanced Nurse
Practitioner (PMHNP-BC) and the beneficiary for the purpose of
evaluation. The initial Psychiatric Diagnostic Assessment includes a
history, mental status and a disposition, and may include
communication with family or other sources, ordering and medical
interpretation of laboratory or other medical diagnostic studies. (See
Section 224.000 for requirements.)
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: This service
must be billed as 1 per episode.
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS:

Date of service

Start and stop times

Place of service

Diagnosis (all 5 Axes)

Diagnostic impression

Psychiatric assessment

Functional assessment

Discharge criteria

Physician's or Adult Psychiatric Mental Health Advanced Nurse
Practitioner’s/Family Psychiatric Mental Health Advanced
Nurse Practitioner’s signature indicating medical
necessity/credentials/date of signature
NOTES and COMMENTS: The initial Psychiatric Diagnostic
Assessment can only be provided to a new patient.
Only one (1) Psychiatric Diagnostic Assessment (whether Initial or
Continuing Care) is allowed per State Fiscal Year.
90792
U7
SERVICE: Psychiatric Diagnostic Assessment – Initial
Use the above definition and requirements.
Section II-47
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
ADDITIONAL INFORMATION: Use code 90792 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
90792
HA, U2
SERVICE: Psychiatric Diagnostic Assessment - Continuing Care
DEFINITION: A direct face-to-face service contact occurring between
the physician or the Adult Psychiatric Mental Health Advanced Nurse
Practitioner/Family Psychiatric Mental Health Advanced Nurse
Practitioner (PMHNP-BC) and the beneficiary during an episode of care
for the purpose of evaluation. The continuing care Psychiatric
Diagnostic Assessment includes a Psychiatric assessment, mental
status examination, functional assessment, medications and a
disposition, and may include communication with family or other
sources, ordering and medical interpretation of laboratory or other
medical diagnostic studies. (See Section 224.000 for requirements.)
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: This service
must be billed as 1 per episode.
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS:

Date of service

Start and stop times

Place of service

Diagnosis (all 5 Axes)

Psychiatric assessment

Functional assessment

Mental status examination

Medications

Discharge criteria

Physician's or Adult Psychiatric Mental Health Advanced Nurse
Practitioner’s/Family Psychiatric Mental Health Advanced
Nurse Practitioner’s signature indicating medical
necessity/credentials/date of signature
NOTES and COMMENTS: The continuing care Psychiatric Diagnostic
Assessment is for established patients only. It must be performed, at a
minimum, at least every 12 months for established patients.
Only one (1) Psychiatric Diagnostic Assessment (whether Initial or
Continuing Care) is allowed per State Fiscal Year.
90792
U7, U1
SERVICE: Psychiatric Diagnostic Assessment – Continuing Care:
Use the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90792 with modifier “U7, U1”
Section II-48
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
to claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
90885
HA, U2
SERVICE: Master Treatment Plan
DEFINITION: A developed plan in cooperation with the beneficiary
(parent or guardian if the beneficiary is under 18), to deliver specific
mental health services to the beneficiary to restore, improve or stabilize
the beneficiary’s mental health condition. The plan must be based on
individualized service needs identified in the completed Mental Health
Diagnostic Evaluation. The plan must include goals for the medically
necessary treatment of identified problems, symptoms and mental
health conditions. The plan must identify individuals or treatment
teams responsible for treatment, specific treatment modalities
prescribed for the beneficiary, time limitations for services and
documentation of medical necessity by the supervising physician.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 8
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
Home (12); Nursing Facility (32); Skilled Nursing Facility (31); School
(03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
(14); ICF/IID (54)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service (date plan is developed)

Start and stop times for development of plan

Place of service

Diagnosis

Beneficiary’s strengths and needs

Treatment goal(s) developed in cooperation with and as stated
by beneficiary that are related specifically to the beneficiary’s
strengths and needs

Measurable objectives

Treatment modalities — The specific services that will be used
to meet the measurable objectives

Projected schedule for service delivery, including amount,
scope and duration

Credentials of staff who will be providing the services

Discharge criteria

Signature/credentials of staff drafting the document and primary
staff who will be delivering or supervising the delivery of the
specific services/ date of signature(s)

Beneficiary’s signature (or signature of parent, guardian, or
custodian of beneficiaries under the age of 18)/date of
Section II-49
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
signature

Physician's signature indicating medical necessity/date of
signature
NOTES and COMMENTS: The service formerly coded as T1023 and
titled “Assessment and Treatment Plan/Plan of Care” is now
incorporated into this service. This service may be billed one (1) time
upon entering care and once yearly thereafter. The master treatment
plan must be reviewed every ninety (90) calendar days or more
frequently if there is documentation of significant acuity changes in
clinical status requiring an update/change in the beneficiary’s master
treatment plan. It is the responsibility of the primary mental health
professional to ensure that all paraprofessionals working with the client
have a clear understanding and work toward the goals and objectives
stated on the treatment plan.
90885
HA
SERVICE: Periodic Review of Master Treatment Plan
DEFINITION: The periodic review and revision of the master treatment
plan, in cooperation with the beneficiary, to determine the beneficiary’s
progress or lack of progress toward the master treatment plan goals
and objectives; the efficacy of the services provided and continued
medical necessity of services. This includes a review and revision of
the measurable goals and measurable objectives directed at the
medically necessary treatment of identified symptoms/mental health
condition, individuals or treatment teams responsible for treatment,
specific treatment modalities and necessary accommodations that will
be provided to the beneficiary, time limitations for services and the
medical necessity of continued services. Services are to be congruent
with the age, strengths, necessary accommodations for any disability
and cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 2
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 10
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); Nursing Facility (32); Skilled Nursing Facility (31); School
(03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
(14); ICF/IID (54)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):
Completed by the primary MHP (If not, then must have a rationale for
another MHP completing the documentation and only with input from
the primary MHP.)

Date of service

Start and stop times for review and revision of plan

Place of service

Diagnosis and pertinent interval history

Beneficiary’s updated strengths and needs

Progress/regression with regard to treatment goal(s) as
Section II-50
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
documented in the master treatment plan

Progress/regression of the measurable objectives as
documented in the master treatment plan

Individualized rationale to support the medical necessity of
continued services

Updated schedule for service delivery, including amount, scope
and duration

Credentials of staff who will be providing the services

Modifications to discharge criteria

Signature/credentials of staff drafting the document and primary
staff who will be delivering or supervising the delivery of the
specific services/date of signature(s)

Beneficiary’s signature (or signature of parent, guardian or
custodian of beneficiaries under the age of 18)/date of
signature(s)

Physician’s signature indicating continued medical
necessity/date of signature
NOTES and COMMENTS: This service must be provided every ninety
(90) days or more frequently if there is documentation of significant
change in acuity or change in clinical status requiring an
update/change in the beneficiary’s master treatment plan. If progress
is not documented, then modifications should be made in the master
treatment plan or rationale why continuing to provide the same type
and amount of services is expected to achieve progress/outcome. It is
the responsibility of the primary mental health professional to ensure
that all paraprofessionals working with the client have a clear
understanding and work toward the goals and objectives stated on the
treatment plan.
90885
HA, U1
Periodic Review of Master Treatment Plan
Apply the above description.
ADDITIONAL INFORMATION: Use code 90885 with modifier “U1” to
claim for this service when provided by a non-physician.
90887
HA, U2
SERVICE: Interpretation of Diagnosis
DEFINITION: A face-to-face therapeutic intervention provided to a
beneficiary in which the results/implications/diagnoses from a mental
health diagnosis evaluation or a psychological evaluation are explained
by the professional who administered the evaluation. Services are to
be congruent with the age, strengths, necessary accommodations and
cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 16
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); Nursing Facility (32); Skilled Nursing Facility (31); School
(03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
(14); ICF/IID (54); Other Locations (99)
Section II-51
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

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 intervention used that must coincide with the
master treatment plan or proposed master treatment plan or
recommendations

Participant response and feedback

Any changes or revision to the master treatment plan,
diagnosis or medication(s)

Staff signature/credentials/date of signature(s)
NOTES AND COMMENTS: 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-toface with the beneficiary and the spouse, legal guardian or significant
other.
90887
U3, U7
Interpretation of Diagnosis
Use above definition and requirements
ADDITIONAL INFORMATION: Use code 90887 with modifier “U3, U7”
to claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
H0004
HA
SERVICE: Individual Psychotherapy
DEFINITION: Face-to-face treatment provided by a licensed mental
health professional on an individual basis. Services consist of
structured sessions that work toward achieving mutually defined goals
as documented in the master treatment plan. Services are to be
congruent with the age, strengths, needed accommodations necessary
for any disability and cultural framework of the beneficiary and his/her
family. The treatment service must reduce or alleviate identified
symptoms, maintain or improve level of functioning or prevent
deterioration.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 48
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Nursing Facility (32); Skilled Nursing Facility
(31); ICF/IID (54); Telemedicine (99)
Section II-52
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
AGE GROUP(S): U21, but not for beneficiaries under the age of 3
except in documented exceptional cases
REQUIRED DOCUMENTATION (See Section 226.200 for additional
requirements):

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 intervention used that must
coincide with the master treatment plan

Beneficiary’s response to intervention that includes current
progress or regression and prognosis

Any revisions indicated for the master treatment plan, diagnosis
or medication(s)

Plan for next individual therapy session, including any
homework assignments and/or advanced psychiatric directive

Staff signature/credentials/date of signature
NOTES and COMMENTS: Services provided must be congruent with
the objectives and interventions articulated on the most recent
treatment plan. 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.
H0004
—
Individual Psychotherapy
Use above definition and requirements.
ADDITONAL INFORMATION: Use code H0004 with no modifier to
claim for services provided to beneficiaries ages 21 and over.
H0004
U7
Individual Psychotherapy
Use above definition and requirements.
ADDITIONAL INFORMATION: Use code H0004 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
90846
HA, U3
SERVICE: Marital/Family Psychotherapy – Beneficiary is not
present
DEFINITION: Face-to-face treatment provided to more than one
member of a family simultaneously in the same session or treatment
with an individual family member (i.e., spouse or single parent) that is
specifically related to achieving goals identified on the beneficiary’s
master treatment plan. The identified beneficiary is not present for this
service. Services are to be congruent with the age, strengths, needed
accommodations for any disability and cultural framework of the
beneficiary and his/her family. These services identify and address
marital/family dynamics and improve/strengthen marital/family
Section II-53
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
interactions and functioning in relationship to the beneficiary, the
beneficiary’s condition and the condition’s impact on the marital/family
relationship.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
REQUIRES PRIOR AUTHORIZATION
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop times of actual encounter with 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 intervention used that must coincide with the
master treatment plan and improve the impact the beneficiary’s
condition has on the spouse/family and/or improve
marital/family interactions between the beneficiary and the
spouse/family

Spouse/family response to intervention 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

HIPPA-compliant release of information forms, completed,
signed and dated

Staff signature/credentials/date of signature
NOTES and COMMENTS: 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
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.
90846
—
Marital/Family Psychotherapy – Beneficiary is not present
Use the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90846 with no modifier to
claim for services provided to beneficiaries ages 21 and over.
Section II-54
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Definition
90846
U7
Marital/Family Psychotherapy – Beneficiary is not present
Section II
Use the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90846 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
90847
HA, U3
SERVICE: Marital/Family Psychotherapy – Beneficiary is present
DEFINITION: Face-to-face treatment provided to more than one
member of a family simultaneously in the same session or treatment
with an individual family member (i.e., spouse or single parent) that is
specifically related to achieving goals identified on the beneficiary’s
master treatment plan. The identified beneficiary must be present for
this service. Services are to be congruent with the age, strengths,
needed accommodations for disability and cultural framework of the
beneficiary and his/her family. These services are to be utilized to
identify and address marital/family dynamics and improve/strengthen
marital/family interactions and functioning in relationship to the
beneficiary, the beneficiary’s condition and the condition’s impact on
the marital/family relationship.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 48
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

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 intervention used that must
coincide with the master treatment plan and improve the impact
the beneficiary’s condition has on the spouse/family and/or
improve marital/family interactions between the beneficiary and
the spouse/family

Beneficiary and spouse/family’s response to intervention that
includes current progress or regression and prognosis

Any changes indicated for the master treatment plan, diagnosis
or medication(s)
Section II-55
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

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 and COMMENTS: Natural supports may be included in these
sessions if justified in service documentation and if supported in the
master treatment plan. Only one beneficiary per family per therapy
session may be billed.
ADDITIONAL INFORMATION: Use code 90847 with modifiers “HA,
U3” to claim for services provided to beneficiaries under age 21.
90847
—
Marital/Family Psychotherapy – Beneficiary is present
Use the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90847 with no modifier to
claim for services provided to beneficiaries ages 21 and over.
90847
U7
Marital/Family Psychotherapy – Beneficiary is present
Use the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90847 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
92507
HA
Individual Outpatient – Speech Therapy, Speech Language
Pathologist
Scheduled individual outpatient care provided by a licensed speech
pathologist supervised by a physician to a Medicaid-eligible beneficiary
for the purpose of treatment and remediation of a communicative
disorder deemed medically necessary. See the Occupational, Physical
and Speech Therapy Program Provider Manual for specifics of the
speech therapy services.
92507
HA, UB
Individual Outpatient – Speech Therapy, Speech Language
Pathologist Assistant
Scheduled individual outpatient care provided by a licensed speech
pathologist assistant supervised by a qualified speech language
pathologist to a Medicaid-eligible beneficiary for the purpose of
treatment and remediation of a communicative disorder deemed
medically necessary. See the Occupational, Physical and Speech
Therapy Program Provider Manual for specifics of the speech therapy
services.
92508
HA
Group Outpatient – Speech Therapy, Speech Language
Pathologist
Contact between a group of Medicaid-eligible beneficiaries and a
speech pathologist for the purpose of speech therapy and remediation.
See the Occupational, Physical and Speech Therapy Provider Manual
for specifics of the speech therapy services.
92508
HA, UB
Group Outpatient – Speech Therapy, Speech Language
Pathologist Assistant
Section II-56
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
Contact between a group of Medicaid-eligible beneficiaries and a
speech pathologist assistant for the purpose of speech therapy and
remediation. See the Occupational, Physical and Speech Therapy
Provider Manual for specifics of the speech therapy services.
90853
HA, U1
SERVICE: Group Outpatient – Group Psychotherapy
DEFINITION: Face-to-face interventions provided to a group of
beneficiaries on a regularly scheduled basis to improve behavioral or
cognitive problems which either cause or exacerbate mental illness.
The professional uses the emotional interactions of the group’s
members to assist them in implementing each beneficiary’s master
treatment plan. Services are to be congruent with the age, strengths,
needed accommodation for any disability and cultural framework of the
beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); School (03);
Homeless Shelter (04); Assisted Living Facility (13); Group Home (14)
AGE GROUP(S): Ages 4 – 20; Under age 4 by prior authorized
medically needy exception
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

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 intervention and intervention used that must
coincide with master treatment plan

Beneficiary’s response to the group intervention that includes
current progress or regression and prognosis

Any changes indicated for the master treatment plan, diagnosis
or medication(s)

Plan for next group session, including any homework
assignments

Staff signature/credentials/date of signature
NOTES and COMMENTS: This does NOT include psychosocial
groups. Beneficiaries eligible for Group Outpatient – Group
Psychotherapy 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
Section II-57
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
90853
—
Section II
Definition
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.
Group Outpatient – Group Psychotherapy
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90853 with no modifier to
claim for services provided to beneficiaries ages 21 and over.
H2012
HA
SERVICE: Therapeutic Day/Acute Day Treatment
DEFINITION: Short-term daily array of continuous, highly-structured,
intensive outpatient services provided by a mental health professional.
These services are for beneficiaries experiencing acute psychiatric
symptoms that may result in the beneficiary being in imminent danger
of psychiatric hospitalization and are designed to stabilize the acute
symptoms. These direct therapy and medical services are intended to
be an alternative to inpatient psychiatric care and are expected to
reasonably improve or maintain the beneficiary’s condition and
functional level to prevent hospitalization and assist with assimilation to
his/her community after an inpatient psychiatric stay of any length.
These services are to be provided by a team consisting of mental
health clinicians, paraprofessionals and nurses, with physician
oversight and availability. The team composition may vary depending
on clinical and programmatic needs but must at a minimum include a
licensed mental health clinician and physician who provide services
and oversight. 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 must include constant staff supervision of beneficiaries
and physician oversight.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 32
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11)
STAFF to CLIENT RATIO: 1:5 for ages 18 and over; 1:4 for U18
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Start and stop times of actual program participation by
beneficiary

Place of service

Diagnosis and pertinent interval history

Brief mental status and observations
Section II-58
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Rationale for and interventions used that must coincide with the
master treatment plan

Beneficiary’s response to the intervention must include current
progress or lack of progress toward symptom reduction and
attainment of goals

Rationale for continued acute day service, including necessary
changes to diagnosis, master treatment plan or medication(s)
and plans to transition to less restrictive services

Staff signature/credentials
NOTES and COMMENTS: Providers may bill for services only at
times during which beneficiaries participate in program activities.
Providers are expected to sign beneficiaries in and out of the program
to provide medically necessary treatment therapies. However, in order
to be claimed separately, these therapies must be identified on the
master treatment plan and serve a treatment purpose which cannot be
accomplished within the day treatment setting.
See Section 219.110 for additional information.
H2012
UA
Therapeutic Day/Acute Day Treatment
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2012 with modifier “UA” to
claim for services provided to beneficiaries ages 21 and over.
See Section 219.110 for additional information.
H2011
HA
SERVICE: Crisis Intervention
DEFINITION: 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.)
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 72
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); Nursing Facility (32); Skilled Nursing Facility (31); School
(03); Homeless Shelter (04); Assisted Living Facility (13); Group Home
(14); ICF/IID (54); Other Locations (99)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop time of actual encounter with beneficiary and
possible collateral contacts with caregivers or informed persons
Section II-59
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Place of service (When 99 is used, specific location and
rationale for location must be included)

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 and COMMENTS: 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.
H2011
U7
Crisis Intervention
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2011 plus modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
SERVICE: Physical Examination – Psychiatrist or Physician
Physician:
99201
99202
99203
99204
99212
99213
99214
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
HA, UB
Physical Examination – Psychiatric Mental Health Clinical Nurse
Specialist or Psychiatric Mental Health Advanced Nurse
Practitioner
DEFINITION: A general multisystem examination based on age and
risk factors to determine the state of health of an enrolled RSPMI
beneficiary.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 12
PCNS &
PANP:
99201
HA, SA
ALLOWABLE PLACES OF SERVICE: Office (11)
99202
HA, SA
AGE GROUP(S): Ages 21 and over; U21
99203
HA, SA
99204
HA, SA
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):
99212
HA, SA

Start and stop times of actual encounter with beneficiary
99213
HA, SA

Date of service
Section II-60
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
99214
HA, SA
Section II
Definition

Place of service

Identifying information

Referral reason and rationale for examination

Presenting problem(s)

Health history

Physical examination

Laboratory and diagnostic procedures ordered

Health education/counseling

Identification of risk factors

Mental status/clinical observations and impressions

ICD diagnoses

DSM diagnostic impressions to include all five axes

Any changes indicated for the master treatment plan, diagnosis
or medication(s)

Treatment recommendations for findings, medications
prescribed and indicated informed consents

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: This service may be billed only by the
RSPMI provider. The physician, Psychiatric Mental Health Clinical
Nurse Specialist or Psychiatric Mental Health Advanced Nurse
Practitioner may not bill for an office visit, nursing home visit or any
other outpatient medical services procedure for the beneficiary for the
same date of service. Pharmacologic Management may not be billed
on the same date of service as Physical Examination, as
pharmacologic management would be considered one component of
the full physical examination (office visit).
99212
HA, UB
99213
HA, UB
99214
HA, UB
SERVICE: Pharmacologic Management by Physician (formerly
Medication Maintenance by a physician)
DEFINITION: Provision of service tailored to reduce, stabilize or
eliminate psychiatric symptoms by addressing individual goals in the
master treatment plan. 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, necessary accommodations for any disability and cultural
framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 12
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Nursing Facility (32); Skilled Nursing Facility
(31); ICF/IID (54); Telemedicine (99)
Section II-61
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

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 intervention used that must coincide with the
master treatment plan

Beneficiary’s response to intervention that includes current
progress or regression and prognosis

Revisions indicated for the master treatment plan, 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 and COMMENTS: Applies only to medications prescribed to
address targeted symptoms as identified in the master treatment plan.
99212
UB
Pharmacologic Management by Physician
99213
UB
Apply the above definition and requirements.
99214
UB
ADDITIONAL INFORMATION: Use code 99212, 99213 or 99214 with
UB modifier to claim for services provided to beneficiaries ages 21 and
over.
99212
HA, SA
99213
HA, SA
Pharmacologic Management by Psychiatric Mental Health Clinical
Nurse Specialist or Psychiatric Mental Health Advanced Nurse
Practitioner
99214
HA, SA
99212
SA
99213
SA
99214
SA
Apply the above definition for services provided to beneficiaries ages
U21.
Pharmacologic Management by Psychiatric Mental Health Clinical
Nurse Specialist or Psychiatric Mental Health Advanced Nurse
Practitioner
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code 99212, 99213 or 99214 with
SA modifier to claim for services provided to beneficiaries ages 21 and
over.
T1502
—
SERVICE: Medication Administration by a Licensed Nurse
DEFINITION: Administration of a physician-prescribed medication to a
beneficiary. This includes preparing the beneficiary and medication;
Section II-62
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
actual administration of oral, intramuscular and/or subcutaneous
medication; observation of the beneficiary after administration and any
possible adverse reactions and returning the medication to its previous
storage.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Other Locations (99)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Time of the specific procedure

Place of service

Physician’s order must be included in medication log

Staff signature/credentials/date of signature
NOTES and COMMENTS: Applies only to medications prescribed to
address targeted symptoms as identified in the master treatment plan.
Drugs and biologicals that can be self-administered shall not be in this
group unless there is a documented reason the patient cannot selfadminister. Non-prescriptions and biologicals purchased by or
dispensed to a patient are not covered.
H0034
HA, HQ
SERVICE: Group Outpatient – Pharmacologic Management by a
Physician
DEFINITION: Therapeutic intervention provided to a group of
beneficiaries by a licensed physician involving evaluation and
maintenance of the Medicaid-eligible beneficiary on a medication
regimen with simultaneous supportive psychotherapy in a group
setting. This includes evaluating medication prescription;
administration, monitoring and supervision and informing beneficiaries
regarding medication(s) and its potential effects and side effects.
Services are to be congruent with the age, strengths, necessary
accommodations for any disability and cultural framework of the
beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Homeless Shelter
(04); Assisted Living Facility (13); Group Home (14)
AGE GROUP(S): Ages 18 and over
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop times of actual group encounter that includes
identified beneficiary
Section II-63
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Place of service

Number of participants

Diagnosis and pertinent interval history

Focus of group

Brief mental status and observations

Rationale for group intervention and intervention used that must
coincide with master treatment plan

Beneficiary’s response to the group intervention that includes
current progress or regression and prognosis

Any changes indicated for the master treatment plan, diagnosis
or medication(s)

If provided by physician that is not a psychiatrist, then any off
label uses of medications must include documented
consultation with the overseeing psychiatrist

Plan for next group session, including any homework
assignments

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: This service applies only to medications
prescribed to address targeted symptoms as identified in the master
treatment plan. This does NOT include psychosocial groups in
rehabilitative day programs or educational groups. The maximum that
may be served in a specified group is ten (10). Providers may bill for
services only at times during which beneficiaries participate in this
program activity.
36415
HA
SERVICE: Routine Venipuncture for Collection of Specimen
DEFINITION: The process of drawing a blood sample through
venipuncture (i.e., inserting a needle into a vein to draw the specimen
with a syringe or vacutainer) or collecting a urine sample by
catheterization as ordered by a physician or psychiatrist.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1, per routine
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 12
ALLOWABLE PLACES OF SERVICE: Office (11); Assisted Living
Facility (13); Other Locations (99)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Time of the specific procedure

Place of service (When 99 is used, specific location and
rationale for location must be included)

Staff signature/credentials/date of signature(s)
Section II-64
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
NOTES and COMMENTS: This service may be provided only to
beneficiaries taking prescribed psychotropic medication or who have a
substance abuse diagnosis.
90887
HA
SERVICE: Collateral Intervention, Mental Health Professional
DEFINITION: A face-to-face contact by a mental health professional
with caregivers, family members, other community-based service
providers or other participants on behalf of and with the expressed
written consent of an identified beneficiary in order to obtain or share
relevant information necessary to the enrolled beneficiary’s
assessment, master treatment plan and/or rehabilitation. The identified
beneficiary does not have to be present for this service. Services are
to be congruent with the age, strengths, needed accommodations for
any disability and cultural framework of the beneficiary and his/her
family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Patient’s Home
(12); School (03); Homeless Shelter (04); Assisted Living Facility (13);
Group Home (14); Other Locations (99)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Names and relationship to the beneficiary of all persons
involved

Start and stop times of actual encounter with collateral contact

Place of Service (When 99 is used, specific location and
rationale for location must be included)

Client diagnosis necessitating intervention

Document how interventions used address goals and
objectives from the master treatment plan

Information gained from collateral contact and how it relates to
master treatment plan objectives

Impact of information received/given on the beneficiary’s
treatment

Any changes indicated for the master treatment plan, diagnosis
or medication(s)

Plan for next contact, if any

Staff signature/credentials/Date of signature
NOTES and COMMENTS: The collateral intervention must be
identified on the master treatment plan as a medically necessary
service. Medicaid WILL NOT pay for incidental or happenstance
meetings with individuals. For example, a chance meeting with a
beneficiary’s adult daughter at the corner store which results in a
conversation regarding the well-being of the beneficiary may not be
Section II-65
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
billed as a collateral contact.
Billing for interventions performed by a mental health professional must
warrant the need for the higher level of staff licensure. Professional
interventions of a type which could be provided by a paraprofessional
will require documentation of the reason it was needed.
Contacts between individuals in the employment of RSPMI agencies or
facilities are not a billable collateral intervention.
90887
U7
Collateral Intervention, Mental Health Professional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code 90887 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
90887
HA, UB
SERVICE: Collateral Intervention, Mental Health Paraprofessional
DEFINITION: A face-to-face contact by a mental health
paraprofessional with caregivers, family members, other communitybased service providers or other participants on behalf of and with the
expressed written consent of an identified beneficiary in order to obtain
or share relevant information necessary to the enrolled beneficiary’s
assessment, master treatment plan and/or rehabilitation. Services are
to be congruent with the age, strengths, needed accommodation for
any disability and cultural framework of the beneficiary and his/her
family. The identified beneficiary does not have to be present for this
service.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Patient’s Home
(12); School (03); Homeless Shelter (04); Assisted Living Facility (13);
Group Home (14); Other Locations (99)
AGE GROUP(S): Ages 21 and over; U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements:

Date of service

Names and relationship to the beneficiary of all persons
involved

Start and stop times of actual encounter with collateral contact

Place of Service (When 99 is used, specific location and
rationale for location must be included)

Client diagnosis necessitating intervention

Document how interventions used address goals and
objectives from the master treatment plan

Information gained from collateral contact and how it relates to
master treatment plan objectives

Impact of information received/given on the beneficiary’s
treatment
Section II-66
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Any changes indicated for the master treatment plan which
must be documented and communicated to the supervising
MHP for consideration

Plan for next contact, if any

Staff signature/credentials/date of signature
NOTES and COMMENTS: Supervision by a Mental Health
Professional must be documented in personnel files and addressed in
accordance of agency’s policies, quality assurance procedures,
personnel performance evaluations, reports of supervisors or other
equivalent documented method of supervision.
The collateral intervention must be identified on the master treatment
plan as a medically necessary service. Medicaid WILL NOT pay for
incidental or happenstance meetings with individuals. For example, a
chance meeting with a beneficiary’s adult daughter at the corner store
which results in a conversation regarding the well-being of the
beneficiary may not be billed as a collateral contact. Contacts between
individuals in the employment of RSPMI agencies or facilities are not a
billable collateral intervention.
H2011
HA, U6
SERVICE: Crisis Stabilization Intervention, Mental Health
Professional
DEFINITION: Scheduled face-to-face treatment activities provided to a
beneficiary who has recently experienced a psychiatric or behavioral
crisis that are expected to further stabilize, prevent deterioration and
serve as an alternative to 24-hour inpatient care. Services are to be
congruent with the age, strengths, needed accommodation for any
disability and cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 72
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Other Locations (99)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop time of actual encounter with beneficiary

Place of service (When 99 is used, specific location and
rationale for location must be included)

Diagnosis and pertinent interval history

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 intervention that includes current
Section II-67
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
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

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: 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.
H2011
U2
Crisis Stabilization Intervention, Mental Health Professional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2011 with modifier “U2” to
claim for services provided to beneficiaries ages 21 and over.
H2011
U2, U7
Crisis Stabilization Intervention, Mental Health Professional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2011 with modifier “U2,
U7” to claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
H2011
HA, U5
SERVICE: Crisis Stabilization Intervention, Mental Health
Paraprofessional
DEFINITION: Scheduled face-to-face treatment activities provided to a
beneficiary who has recently experienced a psychiatric or behavioral
crisis that are expected to further stabilize, prevent deterioration and
serve as an alternative to 24-hour inpatient care. Services are to be
congruent with the age, strengths, needed accommodation for any
disability and cultural framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
extension: 72
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Other Locations (99)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service

Start and stop time of actual encounter with beneficiary

Place of service (When 99 is used, specific location and
rationale for location must be included)

Diagnosis and pertinent interval history

Behavioral observations
Section II-68
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Consult with MHP or physician regarding events that
necessitated this service and the review of the outcome of the
intervention

Intervention used must coincide with the master treatment plan,
psychiatric advance directive or crisis plan which must be
documented and communicated to the supervising MHP

Beneficiary’s response to intervention that includes current
progress or regression

Plan for next session, including any homework assignments

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: 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.
Supervision by a Mental Health Professional must be documented and
addressed in personnel files in accordance with the agency’s policies,
quality assurance procedures, personnel performance evaluations,
reports of supervisors or other equivalent documented method of
supervision.
H2011
U1
Crisis Stabilization Intervention, Mental Health Paraprofessional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2011 with modifier “U1” to
claim for services provided to beneficiaries ages 21 and over.
H2015
HA, U5
SERVICE: Intervention, Mental Health Professional (formerly OnSite and Off-Site Interventions, MHP)
DEFINITION: Face-to-face medically necessary treatment activities
provided to a beneficiary consisting of specific therapeutic interventions
as prescribed on the master treatment plan to re-direct a beneficiary
from a psychiatric or behavioral regression or to improve the
beneficiary’s progress toward specific goal(s) and outcomes. These
activities may be either scheduled or unscheduled as the goal
warrants. Services are to be congruent with the age, strengths,
necessary accommodations for any disability and cultural framework of
the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Other Locations (99)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Start and stop times of actual encounter with beneficiary

Date of service
Section II-69
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Place of service, (When 99 is used, specific location and
rationale for location must be included)

Client diagnosis necessitating intervention

Brief mental status and observations

Document how interventions used address goals and
objectives from the master treatment plan

Beneficiary’s response to intervention that includes current
progress or regression and prognosis

Any changes indicated for the master treatment plan, diagnosis
or medication(s)

Plan for next intervention, including any homework
assignments

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: Interventions of a type that could be
performed by a paraprofessional may not be billed at a mental health
professional rate unless the medical necessity for higher level staff is
clearly documented.
H2015
U6
Intervention, Mental Health Professional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2015 with modifier “U6” to
claim for services provided to beneficiaries ages 21 and over.
H2015
U7
Intervention, Mental Health Professional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2015 with modifier “U7” to
claim for services provided via telemedicine only.
NOTE: Telemedicine POS 99
H2015
HA, U1
SERVICE: Intervention, Mental Health Paraprofessional (formerly
On-Site and Off-Site Intervention, Mental Health Paraprofessional)
DEFINITION: Face-to-face, medically necessary treatment activities
provided to a beneficiary consisting of specific therapeutic interventions
prescribed on the master treatment plan, which are expected to
accomplish a specific goal or objective listed on the master treatment
plan. These activities may be either scheduled or unscheduled as the
goal or objective warrants. Services are to be congruent with the age,
strengths, necessary accommodations for any disability and cultural
framework of the beneficiary and his/her family.
DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary’s
Home (12); School (03); Homeless Shelter (04); Assisted Living Facility
(13); Group Home (14); Other Locations (99)
AGE GROUP(S): U21
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
Section II-70
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
additional requirements):

Date of service

Start and stop times of actual encounter with beneficiary

Place of service (When 99 is used, specific location and
rationale for location must be included)

Client diagnosis necessitating intervention

Document how interventions used address goals and
objectives from the master treatment plan

Beneficiary’s response to intervention that includes current
progress or regression and prognosis

Plan for next intervention, including any homework
assignments

Staff signature/credentials/date of signature(s)
NOTES and COMMENTS: Billing for this service does not include
time spent transporting the beneficiary to a required service, nor does it
include time spent waiting while a beneficiary attends a scheduled or
unscheduled appointment. Supervision by a Mental Health
Professional must be documented and addressed in personnel files in
accordance with the agency’s policies, quality assurance procedures,
personnel performance evaluations, reports of supervisors or other
equivalent documented method of supervision.
H2015
U2
Intervention, Mental Health Paraprofessional
Apply the above definition and requirements.
ADDITIONAL INFORMATION: Use code H2015 with modifier “U2” to
claim for services provided to beneficiaries ages 21 and over.
H2017
HA, U1
SERVICE: Rehabilitative Day Service for Persons under Age 18
DEFINITION: An array of face-to-face rehabilitative day activities
providing a preplanned and structured group program for identified
beneficiaries that improve emotional and behavioral symptoms of youth
diagnosed with childhood disorders, as distinguished from the
symptom stabilization function of acute day treatment. These
rehabilitative day activities are person- and family-centered, ageappropriate, recovery based, culturally competent, must reasonably
accommodate disability and must have measurable outcomes. These
activities are designed to assist the beneficiary with compensating for
or eliminating functional deficits and interpersonal and/or
environmental barriers associated with their mental illness. The intent
of these services is to enhance a youth’s functioning in the home,
school and community with the least amount of ongoing professional
intervention. Skills addressed may include: emotional skills, such as
coping with stress, anxiety or anger; behavioral skills, such as positive
peer interactions, appropriate social/family interactions and managing
overt expression of symptoms like impulsivity and anger; daily living
and self-care skills, such as personal care and hygiene and daily
structure/use of time; cognitive skills, such as problem solving,
developing a positive self-esteem and reframing, money management,
community integration and understanding illness, symptoms and the
proper use of medications and any similar skills required to implement
Section II-71
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
a beneficiary’s master treatment plan.
DAILY MAXIMUM UNITS THAT MAY BE BILLED: 16 for ages 0-17
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 80 for ages
0-17
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); School (03);
Assisted Living Facility (13); Group Home (14); Other Locations (99)
(churches, community centers, space donated solely for clinical
services and appropriate community locations tied to the beneficiary’s
treatment plan)
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS: 1:10
ratio maximum with the provision that client ratio must be reduced
when necessary to accommodate significant issues related to acuity,
developmental status and clinical needs.
AGE GROUP(S): U18
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Start and stop times of actual program participation by
beneficiary

Date of service

Place of service

Client diagnosis necessitating rehabilitative day activities

Behavioral observations

Document how rehabilitative day activities used address goals
and objectives from the master treatment plan

Beneficiary’s participation and response to the rehabilitative
day activities

Staff signature/credentials

Supervising staff signature/credentials/date of signature(s)

A weekly summary, signed by a Mental Health Professional
(the supervising MHP, if applicable), describing rehabilitative
day activities provided and the beneficiary’s progress or lack of
progress in achieving the treatment goal(s) and established
outcomes to be accomplished
NOTES and COMMENTS: Providers may bill for services only at
times during which beneficiaries participate in program activities.
Providers are expected to sign beneficiaries in and out of the program
to provide medically necessary treatment therapies. However, in order
to be claimed separately, these therapies must be identified on the
master treatment plan and serve a treatment purpose which cannot be
accomplished within the day treatment setting.
H2017
—
Rehabilitative Day Service for Persons Ages 18-20
Apply the above definition and requirements (except Staff to Client
Ratios, which are outlined below).
Section II-72
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition
ADDITIONAL INFORMATION: Use code H2017 with no modifier to
claim for services provided to beneficiaries for ages 18-20.
DAILY MAXIMUM UNITS THAT MAY BE BILLED: 24
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 120
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS: 1:15
ratio maximum with the provision that client ratio must be reduced
when necessary to accommodate significant issues related to acuity,
developmental status and clinical needs.
H2017
—
SERVICE: Adult Rehabilitative Day Service
DEFINITION: An array of face-to-face rehabilitative day activities
providing a preplanned and structured group program for identified
beneficiaries that aimed at long-term recovery and maximization of
self-sufficiency, as distinguished from the symptom stabilization
function of acute day treatment. These rehabilitative day activities are
person- and family-centered, recovery-based, culturally competent,
provide needed accommodation for any disability and must have
measurable outcomes. These activities assist the beneficiary with
compensating for or eliminating functional deficits and interpersonal
and/or environmental barriers associated with their chronic mental
illness. The intent of these services is to restore the fullest possible
integration of the beneficiary as an active and productive member of
his/her family, social and work community and/or culture with the least
amount of ongoing professional intervention. Skills addressed may
include: emotional skills, such as coping with stress, anxiety or anger;
behavioral skills, such as proper use of medications, appropriate social
interactions and managing overt expression of symptoms like
delusions or hallucinations; daily living and self-care skills, such as
personal care and hygiene, money management and daily
structure/use of time; cognitive skills, such as problem solving,
understanding illness and symptoms and reframing; community
integration skills and any similar skills required to implement a
beneficiary’s master treatment plan.
DAILY MAXIMUM UNITS THAT MAY BE BILLED: 24
WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 120
PRIOR AUTHORIZATION REQUIRED
ALLOWABLE PLACES OF SERVICE: Office (11); Assisted Living
Facility (13); Group Home (14); Other Locations (99) (churches,
community centers, space donated solely for clinical services and
appropriate community locations tied to the beneficiary’s treatment
plan)
MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS: 1:15
ratio maximum with the provision that client ratio must be reduced
when necessary to accommodate significant issues related to acuity,
developmental status and clinical needs.
AGE GROUP(S): Ages 21 and over
DOCUMENTATION REQUIREMENTS (See Section 226.200 for
additional requirements):

Date of service
Section II-73
Rehabilitative Services for Persons with Mental Illness
National
Code
Required
Modifier
Section II
Definition

Start and stop times of actual program participation by
beneficiary

Place of service

Client diagnosis necessitating rehabilitative day activities

Behavioral observations

Document how rehabilitative day activities used address goals
and objectives from the master treatment plan

Beneficiary’s participation and response to the rehabilitative
day activities

Staff signature/credentials

Supervising staff signature/credentials/date of signature(s)

A weekly summary, signed by a Mental Health Professional
(the supervising MHP, if applicable), describing rehabilitative
day activities provided and the beneficiary’s progress or lack of
progress in achieving the treatment goal(s) and established
outcomes to be accomplished through participation in
rehabilitative day service.
NOTES and COMMENTS: Rehabilitative Day services do NOT
include vocational services and training, academic education, personal
care or home health services, and purely recreational activities and
may NOT be used to supplant services which may be obtained or are
required to be provided by other means. Providers may bill for
services only at times during which beneficiaries participate in program
activities. Providers are expected to sign beneficiaries in and out of the
program to provide medically necessary treatment therapies.
However, in order to be claimed separately, these therapies must be
identified on the master treatment plan and serve a treatment purpose
which cannot be accomplished within the day treatment setting.
252.130
7-1-07
Inpatient Hospital Procedure Codes
RSPMI providers may be reimbursed for the following visits made to patients of acute care
inpatient hospitals by board-certified or board eligible psychiatrists.
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99251
99252
99253
99254
99255
252.140
Telemedicine RSPMI Services Billing Information
9-1-13
The mental health professional may provide certain treatment services from a remote site to the
Medicaid-eligible beneficiary who is located in a mental health clinic setting. See Section
252.410 for billing instructions.
Section II-74
Rehabilitative Services for Persons with Mental Illness
Section II
The following services may be provided via telemedicine by a mental health professional to
Medicaid-eligible beneficiaries under age 21 and Medicaid-eligible beneficiaries age 21 and
over; bill with POS 99:
National Code
Required Modifier
Service Title
90792
U7
Psychiatric Diagnostic Assessment – Initial
90792
U7, U1
Psychiatric Diagnostic Assessment – Continuing
Care
99212
HA, UB
Pharmacologic Management by a Physician
99212
UB
99213
HA, UB
99213
UB
99214
HA, UB
99214
UB
The following services may be provided via telemedicine by a mental health professional to
Medicaid-eligible beneficiaries age 21 and over; bill with POS 99:
National Code
Required Modifier
Service Title
90791
U7
Mental Health Evaluation/Diagnosis
90887
U3, U7
Interpretation of Diagnosis
H0004
U7
Individual Psychotherapy
90846
U7
Marital/Family Psychotherapy – Beneficiary is not
present
90847
U7
Marital/Family Psychotherapy – Beneficiary is
present
H2011
U7
Crisis Intervention
90792
U7, U1
Psychiatric Diagnostic Assessment – Continuing
Care
H2011
U2, U7
Crisis Stabilization Intervention, Mental Health
Professional
H2015
U7
Intervention, Mental Health Professional
99212
HA, UB
Pharmacologic Management by a Physician
99212
UB
99213
HA, UB
99213
UB
99214
HA, UB
99214
UB
90887
U7
Collateral Intervention, Mental Health
Professional
Section II-75
Rehabilitative Services for Persons with Mental Illness
252.150
Section II
Services Available to Residents of Long Term Care Facilities Billing
Information
9-1-13
The following RSPMI procedure codes are payable to an RSPMI provider for services provided
to residents of nursing homes who are Medicaid eligible when prescribed according to policy
guidelines detailed in this manual:
National
Code
Required
Modifier
Service Title
90791
HA, U1
Mental Health Evaluation/Diagnosis
90885
HA, U2
Master Treatment Plan
90885
HA
Periodic Review of Master Treatment Plan
90885
HA, U1
Periodic Review of Master Treatment Plan
90887
U2
Interpretation of Diagnosis
H0004
—
Individual Psychotherapy
H2011
U7
Crisis Intervention
Services provided to nursing home residents may be provided on or off site from the RSPMI
provider. The services may be provided in the long-term care (LTC) facility, if necessary.
252.200
10-4-09
Place of Service Codes
Electronic and paper claims now require the same national place of service codes.
Place of Service
POS Codes
Outpatient Hospital
22
Office (RSPMI Facility Service Site)
11
Patient’s Home
12
Nursing Facility
32
Skilled Nursing Facility
31
School (Including Licensed Child Care
Facility)
03
Homeless Shelter
04
Assisted Living Facility (Including Residential
Care Facility)
13
Group Home
14
ICF/IID
54
Other Locations
99
RSPMI Clinic (Telemedicine)
99
Emergency Services in ER
23
Section II-76
Rehabilitative Services for Persons with Mental Illness
252.300
Section II
7-1-07
Billing Instructions - Paper Only
Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore,
claims submitted on paper are paid once a month. The only claims exempt from this process are
those that require attachments or manual pricing.
To bill for RSPMI services, use the CMS-1500 form The numbered items correspond to
numbered fields on the claim form. View a CMS-1500 sample form.
When completing the CMS-1500, accuracy, completeness and clarity are important. Claims
cannot be processed if applicable information is not supplied or is illegible. Claims should be
typed whenever possible.
Completed claim forms should be forwarded to Hewlett Packard Enterprise. View or print
Hewlett Packard Enterprise Claims contact information.
NOTE: A provider rendering services without verifying eligibility for each date of service
does so at the risk of not being reimbursed for the services.
252.310
Completion of the CMS-1500 Claim Form
Field Name and Number
Instructions for Completion
1.
Not required.
(type of coverage)
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
12-15-14
Beneficiary’s or participant’s 10-digit Medicaid or
ARKids First-A or ARKids First-B identification
number.
2.
PATIENT’S NAME (Last
Name, First Name, Middle
Initial)
Beneficiary’s or participant’s last name and first
name.
3.
PATIENT’S BIRTH DATE
Beneficiary’s or participant’s date of birth as given on
the individual’s Medicaid or ARKids First-A or ARKids
First-B identification card. Format: MM/DD/YY.
SEX
Check M for male or F for female.
4.
INSURED’S NAME (Last
Name, First Name, Middle
Initial)
Required if insurance affects this claim. Insured’s last
name, first name, and middle initial.
5.
PATIENT’S ADDRESS (No.,
Street)
Optional. Beneficiary’s or participant’s complete
mailing address (street address or post office box).
CITY
Name of the city in which the beneficiary or
participant resides.
STATE
Two-letter postal code for the state in which the
beneficiary or participant resides.
ZIP CODE
Five-digit zip code; nine digits for post office box.
TELEPHONE (Include Area
Code)
The beneficiary’s or participant’s telephone number
or the number of a reliable message/contact/
emergency telephone
6.
PATIENT RELATIONSHIP TO
INSURED
If insurance affects this claim, check the box
indicating the patient’s relationship to the insured.
7.
INSURED’S ADDRESS (No.,
Street)
Required if insured’s address is different from the
patient’s address.
Section II-77
Rehabilitative Services for Persons with Mental Illness
Field Name and Number
Section II
Instructions for Completion
CITY
STATE
ZIP CODE
TELEPHONE (Include Area
Code)
8.
RESERVED
Reserved for NUCC use.
9.
OTHER INSURED’S NAME
(Last name, First Name,
Middle Initial)
If patient has other insurance coverage as indicated
in Field 11d, the other insured’s last name, first name,
and middle initial.
a.
OTHER INSURED’S
POLICY OR GROUP
NUMBER
Policy and/or group number of the insured individual.
b.
RESERVED
Reserved for NUCC use.
SEX
Not required.
c.
RESERVED
Reserved for NUCC use.
d.
INSURANCE PLAN
NAME OR PROGRAM
NAME
Name of the insurance company.
10. IS PATIENT’S CONDITION
RELATED TO:
a.
EMPLOYMENT? (Current
or Previous)
Check YES or NO.
b.
AUTO ACCIDENT?
Required when an auto accident is related to the
services. Check YES or NO.
PLACE (State)
If 10b is YES, the two-letter postal abbreviation for
the state in which the automobile accident took place.
c.
OTHER ACCIDENT?
Required when an accident other than automobile is
related to the services. Check YES or NO.
d.
CLAIM CODES
The “Claim Codes” identify additional information
about the beneficiary’s condition or the claim. When
applicable, use the Claim Code to report appropriate
claim codes as designated by the NUCC. When
required to provide the subset of Condition Codes,
enter the condition code in this field. The subset of
approved Condition Codes is found at
www.nucc.org under Code Sets.
11. INSURED’S POLICY GROUP
OR FECA NUMBER
a.
b.
Not required when Medicaid is the only payer.
INSURED’S DATE OF
BIRTH
Not required.
SEX
Not required.
OTHER CLAIM ID
NUMBER
Not required.
Section II-78
Rehabilitative Services for Persons with Mental Illness
Field Name and Number
Section II
Instructions for Completion
c.
INSURANCE PLAN
NAME OR PROGRAM
NAME
Not required.
d.
IS THERE ANOTHER
HEALTH BENEFIT
PLAN?
When private or other insurance may or will cover
any of the services, check YES and complete items
9, 9a and 9d. Only one box can be marked.
12. PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE
Enter “Signature on File,” “SOF” or legal signature.
13. INSURED’S OR
AUTHORIZED PERSON’S
SIGNATURE
Enter “Signature on File,” “SOF” or legal signature.
14. DATE OF CURRENT:
Required when services furnished are related to an
accident, whether the accident is recent or in the
past. Date of the accident.
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
Enter the qualifier to the right of the vertical dotted
line. Use Qualifier 431 Onset of Current Symptoms or
Illness; 484 Last Menstrual Period.
15. OTHER DATE
Enter another date related to the beneficiary’s
condition or treatment. Enter the qualifier between the
left-hand set of vertical, dotted lines.
The “Other Date” identifies additional date information
about the beneficiary’s condition or treatment. Use
qualifiers:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-Ray
471 Prescription
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date)
444 First Visit or Consultation
16. DATES PATIENT UNABLE TO
WORK IN CURRENT
OCCUPATION
Not required.
17. NAME OF REFERRING
PROVIDER OR OTHER
SOURCE
Primary Care Physician (PCP) referral is required for
RSPMI services for individuals under age 21. If
services are the result of a Child Health Services
(EPSDT) screening/ referral, enter the referral
source, including name and title.
17a. (blank)
The 9-digit Arkansas Medicaid provider ID number of
the referring physician.
17b. NPI
Not required.
Section II-79
Rehabilitative Services for Persons with Mental Illness
Section II
Field Name and Number
Instructions for Completion
18. HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
When the serving/billing provider’s services charged
on this claim are related to a beneficiary’s or
participant’s inpatient hospitalization, enter the
individual’s admission and discharge dates. Format:
MM/DD/YY.
19.
Identifies additional information about the
beneficiary’s condition or the claim. Enter the
appropriate qualifiers describing the identifier. See
www.nucc.org for qualifiers.
ADDITIONAL CLAIM
INFORMATION
20. OUTSIDE LAB?
$ CHARGES
21. DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Not required.
Not required.
Enter the applicable ICD indicator to identify which
version of ICD codes is being reported.
Use “9” for ICD-9-CM.
Use “0” for ICD-10-CM.
Enter the indicator between the vertical, dotted lines
in the upper right-hand portion of the field.
Diagnosis code for the primary medical condition for
which services are being billed. Use the appropriate
International Classification of Diseases (ICD). List no
more than 12 diagnosis codes. Relate lines A-L to the
lines of service in 24E by the letter of the line. Use
the highest level of specificity.
22. RESUBMISSION CODE
ORIGINAL REF. NO.
Reserved for future use.
Any data or other information listed in this field does
not/will not adjust, void or otherwise modify any
previous payment or denial of a claim. Claim payment
adjustments, voids, and refunds must follow
previously established processes in policy.
23. PRIOR AUTHORIZATION
NUMBER
The prior authorization or benefit extension control
number if applicable.
24A.
The “from” and “to” dates of service for each billed
service. Format: MM/DD/YY.
DATE(S) OF SERVICE
1. On a single claim detail (one charge on one line),
bill only for services provided within a single
calendar month.
2. Providers may bill on the same claim detail for
two or more sequential dates of service within the
same calendar month when the provider
furnished equal amounts of the service on each
day of the date sequence.
B.
PLACE OF SERVICE
Two-digit national standard place of service code.
See Section 252.200 for codes.
C.
EMG
Enter “Y” for “Yes” or leave blank if “No.” EMG
identifies if the service was an emergency.
Section II-80
Rehabilitative Services for Persons with Mental Illness
Field Name and Number
D.
Section II
Instructions for Completion
PROCEDURES,
SERVICES, OR
SUPPLIES
CPT/HCPCS
Enter the correct CPT or HCPCS procedure codes
from Sections 252.100 through 252.150.
MODIFIER
Use applicable modifier.
E.
DIAGNOSIS POINTER
Enter the diagnosis code reference letter (pointer) as
shown in Item Number 21 to relate to the date of
service and the procedures performed to the primary
diagnosis. When multiple services are performed, the
primary reference letter for each service should be
listed first; other applicable services should follow.
The reference letter(s) should be A-L or multiple
letters as applicable. The “Diagnosis Pointer” is the
line letter from Item Number 21 that relates to the
reason the service(s) was performed.
F.
$ CHARGES
The full charge for the service(s) totaled in the detail.
This charge must be the usual charge to any client,
patient, or other beneficiary of the provider’s services.
G.
DAYS OR UNITS
The units (in whole numbers) of service(s) provided
during the period indicated in Field 24A of the detail. .
H.
EPSDT/Family Plan
Enter E if the services resulted from a Child Health
Services (EPSDT) screening/referral.
I.
ID QUAL
Not required.
J.
RENDERING PROVIDER
ID #
The 9-digit Arkansas Medicaid provider ID number of
the individual who furnished the services billed for in
the detail.
NPI
Not required.
25. FEDERAL TAX I.D. NUMBER
Not required. This information is carried in the
provider’s Medicaid file. If it changes, please contact
Provider Enrollment.
26. PATIENT’S ACCOUNT NO.
Optional entry that may be used for accounting
purposes; use up to 16 numeric or alphabetic
characters. This number appears on the Remittance
Advice as “MRN.”
27. ACCEPT ASSIGNMENT?
Not required. Assignment is automatically accepted
by the provider when billing Medicaid.
28. TOTAL CHARGE
Total of Column 24F—the sum all charges on the
claim.
29. AMOUNT PAID
Enter the total of payments previously received on
this claim. Do not include amounts previously paid by
Medicaid. Do not include in this total the
automatically deducted Medicaid or ARKids First-B
co-payments.
30. RESERVED
Reserved for NUCC use.
Section II-81
Rehabilitative Services for Persons with Mental Illness
Section II
Field Name and Number
Instructions for Completion
31. SIGNATURE OF PHYSICIAN
OR SUPPLIER INCLUDING
DEGREES OR
CREDENTIALS
The provider or designated authorized individual must
sign and date the claim certifying that the services
were personally rendered by the provider or under
the provider’s direction. “Provider’s signature” is
defined as the provider’s actual signature, a rubber
stamp of the provider’s signature, an automated
signature, a typewritten signature, or the signature of
an individual authorized by the provider rendering the
service. The name of a clinic or group is not
acceptable.
32. SERVICE FACILITY
LOCATION INFORMATION
Enter the name and street, city, state, and zip code of
the facility where services were performed.
a. (blank)
Not required.
b. Service Site Medicaid ID
number
Enter the 9-digit Arkansas Medicaid provider ID
number of the service site.
33. BILLING PROVIDER INFO &
PH #
Billing provider’s name and complete address.
Telephone number is requested but not required.
a. (blank)
Not required.
b. (blank)
Enter the 9-digit Arkansas Medicaid provider ID
number of the billing provider.
252.400
Special Billing Procedures
252.410
RSPMI Billing Instructions
7-1-07
RSPMI Medicaid providers who provide covered telemedicine services must comply with the
definitions and coding requirements outlined below when billing Medicaid.
1.
Telemedicine transactions involve interaction between a mental health professional
and a beneficiary who are in different locations. The beneficiary must be in a mental
health clinic setting.
Telemedicine Site Definitions
2.
Local Site:
The local site is the patient’s location.
Remote Site:
The remote site is the location of the mental health
professional performing a telemedicine service for the
beneficiary at the local site.
The place of service code is determined by the patient’s location (the local site). The
remote site is never the place of service.
Telemedicine Place of Service Codes
Paper Claims Code = H, Electronic Claims Code = 99 RSPMI Clinic
(Telemedicine)
252.420
Non-Covered Diagnosis Codes
10-1-15
RSPMI services are not covered by Arkansas Medicaid for an individual of any age whose
primary diagnosis is substance abuse. A claim filed for any RSPMI service will be denied if
the primary diagnosis code is one of the following. (View ICD codes.)
Section II-82
Rehabilitative Services for Persons with Mental Illness
Section II
For an RSPMI provider delivering an RSPMI service, the primary diagnosis is the DSM-IV mental
health disorder that is the primary focus of the mental health treatment service being delivered.
For persons being treated by an RSPMI 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. Treatment plans should clearly reflect any services that may be needed to
address the co-occurring substance use problems, whether offered by the RSPMI provider or via
a referral to another provider. RSPMI providers that are also substance abuse treatment
providers may also provide substance abuse treatment services to their mental health clients.
These substance abuse treatment services are not billable as an RSPMI service. In the
provision of RSPMI 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.
All RSPMI services must be focused toward and address the mental health needs of the client.
Substance use issues should be addressed and documented within the context of the impact of
the substance use disorder on the mental health disorder that is the focus of the RSPMI service
being delivered.
252.430
Daily Service Billing Exclusions
9-1-13
RSPMI providers may not bill for the following services together on the same date of service:
National Codes and
Modifiers
Service Titles
90885 – HA, U2
AND
90885 – HA or
90885 – HA, U1
Master treatment plan
H2017 – -HA, U1
AND
H2017
Adult Rehabilitative Day Service
AND
U21 Rehabilitative Day Service
90791 – HA, U1
Mental Health Evaluation/Diagnosis
90791 – U7
AND
90885 – HA
AND
90885 – HA, U1
Periodic Review of Master treatment plan
AND
Periodic Review of Master treatment plan
Section II-83
Rehabilitative Services for Persons with Mental Illness
National Codes and
Modifiers
Section II
Service Titles
ONLY 1 OF THE BELOW CODES CAN BE BILLED PER DAY
99212 – HA, UB
Pharmacologic Management by Physician
99212 – UB
99213 – HA, UB
99213 – UB
99214 – HA, UB
99214 – UB
OR
OR
99212 – HA, SA
Pharmacologic Management by Psychiatric Mental Health
Clinical Nurse Specialist or Psychiatric Mental Health Advanced
Nurse Practitioner
99212 – SA
99213 – HA, SA
99213 – SA
99214 – HA, SA
99214 – SA
OR
H0034 – HA, HQ
OR
Group Outpatient – Pharmacologic Management by Physician
H2012 – HA
Therapeutic Day/Acute Day
H2012 – UA
AND
H2017
AND
Adult Rehabilitative Day Service
H2012 – HA
Therapeutic Day/Acute Day
H2012 – UA
AND
H2017 – HA, U1
AND
U21 Rehabilitative Day Service
90792 – HA, U1
Psychiatric Diagnostic Assessment – Initial
90792 – U7
AND
90792 – HA, U2
AND
90792 – U7, U1
Psychiatric Diagnostic Assessment – Continuing Care
AND Any Codes Listed Below
99201 – HA,UB; 99202 –
HA, UB; 99203 – HA, UB;
99204 – HA, UB; 99211 –
HA, UB; 99212 – HA, UB;
Physical Examination
Section II-84
Rehabilitative Services for Persons with Mental Illness
National Codes and
Modifiers
99213 – HA, UB; 99214 –
HA,UB; 99201 – HA,SA;
99202 – HA, SA; 99203 –
HA, SA; 99204 – HA, SA
Section II
Service Titles
99211 – HA, SA
99212 – HA, UB
Pharmacologic Management by Physician
99212 – UB
99213 – HA, UB
99213 – UB
99214 – HA, UB
99214 – UB
99212 – HA, SA
99212 – SA
Pharmacologic Management by Psychiatric Mental Health
Clinical Nurse Specialist or Psychiatric Mental Health Advanced
Nurse Practitioner
99213 – HA, SA
99213 – SA
99214 – HA, SA
99214 – SA
H0034
Group Outpatient – Pharmacologic Management by Physician
Section II-85