Rehabilitative Services Coverage Guidelines

Adult/Children's Mental Health Services

Introduction

Community Mental Health services refers to those services provided with the primary purpose of diagnosis, treatment, and/or rehabilitation of a mental disorder, or a dysfunction related to a mental disorder. All services are reimbursable only when provided in accordance with a treatment plan approved by a licensed physician or other licensed practitioner of the healing arts.

Provider Participation

The Rhode Island Medicaid Program will reimburse qualified providers for those services provided to eligible recipients of the RI Medicaid Program who meet the criteria listed below.

Services are reimbursable only when provided in accordance with a treatment plan approved by a physician or other licensed practitioner of the healing arts.

A licensed practitioner of the healing arts is defined as a:

1. Physician
2. Licensed Psychologist
3. Registered Nurse licensed to practice under Rhode Island State Law
4. Certified Independent Social Worker (CISW) as defined in Rhode Island General Laws, Chapter 39.

Exclusions to this general rule include:

1. Crisis Intervention Services, which may be both recommended and delivered by the mental health professional on duty at the time of the crisis without the need for a treatment plan or approval by a licensed practitioner of the healing arts.
2. Mental Health Psychiatric Rehabilitative Residence services which require physician authorization on the treatment plan and must be supervised by a registered nurse.

Adult Mental Health

Documentation Required for Authorization OF Mental Health Outpatient Visits in Excess OF 20

Providers must submit the following documentation for authorization of services for RIte Care recipients who require more than the 20 mental health outpatient visits allowed under RIte Care:

1. A completed Rhode Island Medicaid Prior Authorization Request Form. The client’s date of birth must be clearly shown on this form directly below the “Non-Medicaid Provider Number.”
2. The specific DSM-X diagnosis(es) being treated, both written and coded. Include all DSM-X Axes. A diagnostic formulation may also be included.
3. A list of current symptoms showing both frequency and severity.
4. A narrative description of the client’s functional level. This description should support the GAF score entered on Axis V of the diagnosis.
5. Description of progress in treatment to date clearly documenting the specific reason or rationale for all treatment procedures.
6. A written, comprehensive, individualized treatment plan that documents the medical necessity of services for which authorization is being requested.

The plan must reflect the client’s clinical needs, problems and/or condition; must clearly delineate and objectively specify the services, activities and programs necessary to meet the client’s needs; and must contain the specific goals and objectives that the client is expected to achieve as a result of the proposed treatment. These goals and objectives should be described in terms of specific, measurable and observable changes in behavior, skills and/or circumstances and include measurable indices of progress along with a projected date of achievement. The frequency, amount and duration of each specific intervention should be clearly evident in the plan and should reflect the figures on the Prior Authorization Request Form.

Note that 15-20 minute visits with a physician or registered nurse , which are generally used for medication maintenance and are thus needed on a frequent bases, and 90 minute medication groups are not to be counted against the 20-visit cap and do not require prior authorization. A maximum of 26 additional visits will be granted at any one time.

All materials must be complete, legible, and received by Gainwell Technologies, PO Box 2010, Warwick, RI 02887, in their entirety at least 30 days before the initial date of service requested. After processing by Gainwell Technologies, the PA request will be forwarded to BHDDH.

Children's Mental Health And Education - DCYF

Authorization for Extended Outpatient Visits

Providers must submit the following documentation for authorization of services for child RIte Care recipients who require more than the 20 mental health outpatient visits allowed under RIte Care:

1. A completed Rhode Island Medicaid Prior Authorization Request Form.
2. Clinician’s diagnostic formulation clearly specifying the specific DSM-IV diagnosis being treated
3. A written, comprehensive, individualized treatment plan that documents the medical necessity of services to be provided. The plan should be prospective in nature, signed and dated by a Licensed Practitioner of the Healing Arts as defined in Section V of the Mental Health Medicaid Policy Manual.
   
   
   
   The plan must reflect the client’s needs and conditions and identity both functional strengths and limitations, must clearly delineate and specify the services necessary to meet the client’s needs, must contain specific goals to be achieved and must contain the objectives for treatment, described in terms of specific measurable and observable changes in behavior and skills which relate to the goals and include measurable indices of progress which coincide with a projected date of achievement.
   
   
   
   The plan must clearly document the specific reason or rationale for all treatment procedures, including each individual problem being addressed, with the frequency, amount and duration of each specific intervention clearly evident in the plan.
4. A description of the client’s functional level using the GAF.

All materials must be complete, legible and received by Gainwell Technologies , PO Box 2010, Warwick, RI 02887-2010 in their entirety at least 30 days before the initial date of service requested. After processing by Hewlett Packard Enterprise, the PA request will be forwarded to DCYF for determination.

A maximum of 12 additional visits will be granted at any one time.

Claims Billing Guidelines

Instructions for completing the CMS 1500 claim forms are in Claims Processing. 

Crisis Intervention

Introduction

Crisis Intervention refers to short term emergency mental health services that are available on a twenty-four hour basis, seven days a week. These services include, but are not limited to, evaluation and counseling, medical treatments including prescribing and administering medications, and intervention at the site of the crisis when clinically appropriate.

Covered Services

Services are covered for both categorically and medically needy Medicaid recipients.

The following table lists all covered crisis intervention services. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Crisis Intervention Services

Procedure CodeDescriptionPA

H2011 U1Crisis Intervention - per 15 minutesN

Provider Participation

Treatment planning may be provided by a wide variety of mental health professionals from areas such as psychiatry, nursing, counseling, rehabilitation, social work, or other mental health specialty areas involved in the individual client’s care/treatment. Staff members directly supervising the provision of care to the client, or the overall program in which the care is provided, may participate in the treatment planning process regardless of their degree or area of specialty.

Community Psychiatric Supported Treatment

Introduction

Community Psychiatric Supported Treatment (CPST) is provided to community-based clients and collaterals by professional mental health staff in accordance with an approved treatment plan for the purpose of insuring the client’s stability and continued community tenure by monitoring and providing medically necessary interventions to assist them in managing the symptoms of their illness and dealing with their overall life situation, including accessing needed medical, social, educational and other services necessary to meeting basic human needs.

Covered Services

The following table lists all covered treatment and counseling services for the Community Psychiatric Supported Treatment (CPST) program. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Community Psychiatric Supported Treatment

Procedure CodeDescriptionPA

H0036Community Psychiatric Supportive Treatment, face to face; per 15 minutesN

H0036 U3Community Psychiatric Supportive Treatment, face to face; per 15 minutes; Supported EmploymentN

H0036 U4Community Psychiatric Supportive Treatment, face to face; per 15 minutes; Substance AbuseN

These services should be billed under your “non-group” provider number, provider type “061.”

Department of Children, Youth and Families (DCYF) Prior Authorized  Services

Introduction

Community mental health services refer to those services provided with the primary purpose of diagnosis, treatment, and/or rehabilitation of a mental disorder, or a dysfunction related to a mental disorder. Services are prior authorized by DCYF and are children’s services.

Covered Services

Services are covered for both categorically and medically needy recipients. Services are covered for EPSDT.

The following table lists all covered DCYF treatment and counseling services that require PA. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Child Mental Health Physician

Procedure CodeDescriptionPA

90791Psychiatric diagnostic interview examination including history, mental status, or dispositionY

 90837Psychotherapy, office/outpatient facility, 60 minutes, face to face with patientY 

90834Psychotherapy, 45 minutes with patient and/or family memberY

90832Psychotherapy, 30 minutes with patient and/or family memberY

H2010Comprehensive medication services, per 15 minutesY

Child Mental Health Psychologist

Procedure CodeDescriptionPA

90791 HPPsychiatric diagnostic interview examination including history, mental status, or dispositionY

90837 HP Psychotherapy, office/outpatient facility, 60 minutes, face to face with patientY

90834 HPPsychotherapy, 45 minutes with patient and/or family memberY

90832 HPPsychotherapy, 30 minutes with patient and/or family memberY

H0004 HQ HPBehavioral health counseling and therapy, per 15 minutes, groupY

90847 HPFamily psychotherapy (with patient present)Y

90846 HPFamily psychotherapy (without patient present)Y

Child Mental Health Psychiatric Nurse

Procedure CodeDescriptionPA

H0031 TDMental health assessment, by non-physiciaY

H0004 TDBehavioral health counseling and therapy, per 15 minutesY

H2010 TDComprehensive medication services, per 15 minutesY

H0004 HQ TDBehavioral health counseling and therapy, per 15 minutesY

Limitations

All DCYF services require prior authorization.

Providers must be approved by DCYF to provide services to recipients in this program.

Patient Liability

There is no recipient co-pay or patient liability for services.