Department of Medical Assistance Services Substance Abuse Services Training

1
Department of Medical Assistance Services
Substance Abuse ServicesTraining

• September 2007

2

• This presentation is to facilitate training of
  the subject matter in portions of the Virginia
  Medicaid manuals on Community Mental Health
  Rehabilitative Services and Psychiatric Services.
  
• It contains only highlights of those manuals and
  is not meant to be a substitute for or take their
  place.
• For complete manual copies go to

www.dmas.virginia.gov
3
General Medicaid Provider Participation
Requirements

• Have administrative and financial management
  capacity to meet federal and state requirements
• Have ability to maintain business and
  professional documentation
• Adhere to conditions outlined in the provider
  agreements
• Notify DMAS of any change in original information
  submitted

4
Participation Requirements contd

• Maintain records that fully document health care
  provided
• Retain records for a period of at least 5 years
  (incl. Remits)
• Furnish access to records and facilities in the
  form and manner requested
• Use Medicaid designated billing forms
• Accept as payment in full the amount reimbursed
  by DMAS. Provider must be participating in the
  Medicaid Program at the time the service is
  performed

5
Participation Requirements contd

• A provider may not bill a client for a covered
  service regardless of whether or not the provider
  received payment from the state
• Should not attempt to collect from the client or
  family member any amount that exceeds the
  Medicaid allowance or for missed appointments

6
Participation Requirements contd

• Hold all recipient information confidential
• Be fully compliant with state and federal HIPAA
  confidentiality, use and disclosure requirements

7
Psychiatric Outpatient Substance Abuse Services
8
Provider Qualifications for Outpatient
Psychiatric SA Services

• An individual licensed by the Virginia
  Department of Health Professions as either a
• Professional Counselor
• Clinical Social Worker
• Psychiatric Clinical Nurse Specialist
• Psychiatric Nurse Practitioner
• Marriage And Family Therapist
• Clinical Psychologist, or
• Physician
• Individual who has completed a graduate degree
  and is under the direct personal supervision of a
  licensed provider

9
Provider Qualifications for Outpatient
Psychiatric SA Services

• In addition to licensure requirements, substance
  abuse treatment providers must also be qualified
  by training and experience in the following areas
  of substance abuse/addiction counseling
• clinical evaluation
• treatment planning
• referral
• service coordination
• client and family education
• documentation professional and ethical
  responsibilities.
• Liscensed SA treament providers may provide out
  pt SA only.

10
Direct Supervision of Unlicensed Personnel

• LMHP SUPERVISOR must be
• Appropriately licensed under state law
• Supervision meets requirements of individual
  profession
• Approves and signs Plan of Care
• Reviews Patients medical history
• Countersigns Plan of Care updates

11
Supervision of Unlicensed Personnel contd

• Reviews each progress note
• Countersigns each progress note on date of
  service indicating note was reviewed
• Meet regularly (every six sessions)
• Discuss Plan of Care
• Review record
• Note Patients progress
• Document supervisory meetings

12
Outpatient Psychiatric Services may be provided
in a

• Practitioners office
• Mental health clinic
• In a group home / nursing home
• In the clients home

13
Criteria for Participation

• To qualify for outpatient psychiatric /
  substance abuse services recipients must meet
  the following criteria
• At risk for developing or requires treatment
  for maladaptive coping strategies and
• Reduction in adaptive and coping mechanisms or
  extreme increase in personal distress and
• Exhibits dysfunctional symptoms and
• Requires treatment to sustain behavioral or
  emotional gains or restore functional levels
• Recipient must meet DSM-IV-TR diagnostic
  criteria for substance abuse or mental health
  disorder. Nicotine or caffeine abuse or
  dependence are not covered. American Society of
  Addiction Medicine (ASAM) criteria will be used
  to determine the appropriate level of treatment.

14
Documentation Required for SA Psychiatric Out
Patient Services

• Results of a Diagnostic Evaluation done within
  the past year (History)
• Description of functional limitations.
• Include full DSM-IV (SA or MH)
• Medical Evaluation (evidence of coordination with
  the PCP, if applicable, or documentation that it
  is not applicable).

15
Documentation Required contd

• Plan(s) of Care, signed and dated by the
  provider.
• Focus of the Plan must
• Be related to the diagnosis
• Indicate client-specific goals related to
  symptoms and behaviors
• Indicate treatment modalities why the modality
  was chosen
• Indicate estimated length treatment will be
  needed frequency of treatments
• Include discharge planning
• Plan of Care must be reviewed every 90 days or
  every sixth session, whichever time frame is
  shorter

16
Documentation Required contd

• Progress Notes for each session
• -Describe how the activities of the session
  relate to the client-specific goals,
• -Document the date, length type of session
• -Describe the level of participation in treatment
• -Contain signature credentials of provider
• A Discharge Summary is required

17
Outpatient Service Limits

• No more than a total of three billed treatment
  interventions in a seven-day period
• Individual psychotherapy
• Group psychotherapy
• Family psychotherapy

18
Service Limits contd

• EXCLUSIONS
• Multiple-family group psychotherapy
• Hypnotherapy
• Interpretation of examinations, procedures data
• Preparations of reports

19
Non-Covered Psychiatric Services

• Broken appointments
• Remedial education
• Day care / respite
• Occupational therapy
• Teaching Grooming skills / ADLs
• Telephone consultations

20
Substance Abuse Services include

• Assessment and evaluation
• Outpatient treatment
• Crisis intervention
• Case management
• Intensive outpatient treatment
• Day treatment
• Opioid treatment

21
SA Assessment Evaluation and Outpatient Services

• Assessment and Evaluation (CPT Codes 90801
  90802)
• Outpatient Individual, Group and Family Therapy
  (CPT Codes 90804-90809, 90812-90815, 90846 -
  90847, 90853 and 90857)
• Medicaid MCOs will establish their own prior
  authorization (PA) criteria and perform
  authorizations
• DMAS will conduct PA for fee-for-service (FFS)

22
Reimbursement for Outpatient SA Treatment

• Rates are the same as corresponding Mental Health
  Outpatient Therapy Services
• CPT code must have the modifier HF associated
  with it
• Reimbursement rates for substance abuse
  outpatient therapy (individual, family, and
  group) services for fee-for-service participants
  may be reviewed at www.dmas.virginia.gov/pr-fee_fi
  les.htm
• Also see included handout

23
SA Outpatient Therapy Limitations

• Individual, family, and group outpatient
  therapies limited to twenty-six sessions per year
• The SA 26 sessions is separate from the MH
  outpatient sessions
• Providers can render SA outpatient therapy
  services, up to 26 sessions without prior
  authorization in the first year of treatment. An
  additional twenty-six sessions may be prior
  authorized in the first year only
• After first treatment year, up to 26 sessions
  available with prior authorization
• If a child under 21 years of age requires
  services beyond these limits, coverage may be
  available through the Early and Periodic
  Screening, Diagnosis, and Treatment program

24
Providers of SA Services

• Currently enrolled independent professional
  providers of outpatient (individual, family, and
  group) services who meet the provider
  qualifications for substance abuse services not
  need to re-enroll with Medicaid
• Currently enrolled community rehabilitative
  substance abuse service providers who meet
  qualifications criteria for substance abuse
  services do not need to re-enroll with Medicaid

25
New Providers of SA Services

• DMAS is enrolling new licensed substance abuse
  treatment practitioners as Medicaid-enrolled
  independent providers
• Mental health clinics will also be able to bill
  for services provided by licensed substance abuse
  treatment practitioners, if clinic has a valid
  Medicaid provider agreement

26
Provider Enrollment Unit Address

• For enrollment, agreements, change of address,
• and enrollment questions contact
• First Health VMAP Provider Enrollment Unit
• P.O. Box 26803
• Richmond, Va. 23261
• Helpline -- 804-270-5105 Richmond
• Toll free -- 888-829-5373
• Fax -- 804-270-7027

27

• Substance Abuse Outpatient Treatment Prior
  Authorization

28
SA Outpatient Therapy PA

• Substance abuse treatment sessions are counted
  separate from the psychiatric services.
• Providers are encouraged to integrate treatment
  for clients with co-occurring psychiatric SA
  conditions
• May have concurrent authorizations for SA
  treatment and psychiatric services.

29
SA Outpatient Therapy PA contd

• Up to 26 sessions without prior authorization in
  the first year of treatment
• An additional twenty-six sessions may be prior
  authorized in the first year only
• After the first treatment year, up to 26 sessions
  are available with prior authorization
• If a child under 21 requires services beyond
  these limits, coverage through Early and Periodic
  Screening, Diagnosis, and Treatment (EPSDT)
  program may be requested

30
SA Outpatient Therapy PA contd

• SA Treatment Practitioners are only eligible to
  provide CPT codes with HF modifiers, excluding
  the evaluation and management codes.
• CPT codes 90804 through 90815, 90846, 90847,
  90853 and 90857 are available for Substance Abuse
  services, with the HF modifier.
• CPT codes 90805, 90807, 90809, 90811, 90813, and
  90815 include medical evaluation and management
  and only psychiatrists, psychiatric nurse
  practitioners and psychiatric clinical nurse
  specialists may bill these codes when
  appropriate.
• Claims for services that exceed the sessions
  available to the individual without authorization
  will be denied.

31
SA Outpatient Therapy PA contd

• Prior Authorization Request Process
• Ask client if they have seen another provider.
• To check if authorization is required for
  additional SA services call the Medicaid HELPLINE
  at 1-800-552-8627
• -- Have the clients Medicaid number
• -- Ask the HELPLINE for the record of
  utilization of psychiatric services
• -- Ask the HELPLINE whether any other
  provider is indicated on the file and the last
  date of service for which a claim was paid.
• --To request prior authorization for SA
  services, submit a fax request to DMAS at
  1-866-364-3526. The fax form (363-A) is available
  in electronically-fillable format on the DMAS
  website at
• www.dmas.virginia.gov

32
SA Outpatient Therapy PA contd

• Initial Review- new provider to recipient
• Clinical information needed from provider for PA
• Axis I Substance Use Disorder Diagnosis
• If dual diagnosis of MH SA, the focus of
  treatment must be provided for the PA request. A
  separate PA request is required for SA and MH if
  the plan is to provide these services
  intermittently.
• -- Describe any potential safety risk within the
  past month
• -- Describe any impairment in functioning
  within the past month
• -- Confirm ASAM Level of Care Assessment
  completed, and recommendation
• -- Confirm recipients ability to comply
  with treatment
• -- Confirm modality (i.e., individual,
  family, group)
• -- Frequency and duration of treatment
• -- Confirm Substance Abuse evaluation/plan
  of care completed, with dated signature of
  qualified provider

33
SA Outpatient Therapy PA contd

• Concurrent Review (same provider)
• Clinical information needed from provider for PA
• Axis I Substance Use Disorder Diagnosis
• All of the following should be available in the
  required Plan of Care and/or 90-Day Update
  required by DMAS
• --Confirm psychosocial assessment completed
• -- Confirm psychiatric and/or medication
  evaluation and/or toxicology screen or
  breathalyzer completed if needed
• -- Symptoms and behaviors within the past 30
  days that support the need for continued
  treatment
• -- Services and compliance within the past
  30 days
• -- Functioning within the past 30 days
• -- Progress, or if little or none, explain
  how this is being addressed

34
SA Outpatient Therapy PA contd

• ADULT Discharge Criteria
• No active cravings for substances that impact
  Activities of Daily Living (ADLs)
• No current preoccupations with getting high or
  past drug experiences that impact ADLs
• Minimal or manageable guilt, remorse, and/or
  shame
• No drug seeking behaviors
• No drug glorification that impact ADLs
• Has attended 80 or more of scheduled sessions
  of therapy sessions in the past month
• Has no uncontrolled abusive or addictive
  behaviors at home, work or in peer interactions
• Has had no positive drug screens or positive
  breathalyzer tests in the last 6 months
• Has family/ peer connections that support
  sobriety.
• Client may be continued in a relapse prevention
  phase for an additional 6 months, to include
• One session of individual or group therapy
  every 2 weeks, or less frequently
• Random urine or breathalyzer monitoring at
  least twice in 6 months
• Encourage attendance at 12-step programs

35
SA Outpatient Therapy PA contd

• ADOLESCENT Discharge Criteria
• No active cravings for substances that impact
  Activities of Daily Living (ADLs)
• No current preoccupations with getting high or
  past drug experiences that impact ADLs
• Minimal or manageable guilt, remorse, and/or
  shame
• No drug seeking behaviors
• No reckless or acting out behaviors directly
  related to substance use/abuse
• Has attended 80 or more of the scheduled therapy
  sessions in the past month
• Has no uncontrolled abusive or addictive
  behaviors at school or in social life
• Has had no positive drug screens or positive
  breathalyzer tests in the last 6 months
• Has family/peer connections that support sobriety
• Client may be continued in a relapse prevention
  phase for an additional 6 months, to include
• One session of individual or group therapy every
  2 weeks, or less frequently
• Random urine or breathalyzer monitoring at least
  twice in 6 months
• Encourage attendance at 12-step programs

36

• Community Substance Abuse Rehabilitative Services

37
Community SA Rehabilitative Services Overview
38
Community SA Rehabilitative Services Overview
(Cont.)
Note Use DMAS limits and unit definitions as
opposed to the national HCPCS codes.
39
Community SA Rehabilitative Services Overview
(Cont.)
40
Qualified Substance Abuse Professional (QSAP)

• A. Individual with completed Masters level
  training in psychology, social work, counseling,
  or rehabilitation who also is either
• (i) certified as substance abuse counselor by the
  Virginia Board of Counseling, or
• (ii) certified addictions counselor by the
  Substance Abuse Certification Alliance of
  Virginia, or
• (iii) holds any certification from the National
  Association of Alcoholism and Drug Abuse
  Counselors, or the International Certification
  and Reciprocity Consortium/Alcohol and Other Drug
  Abuse, Inc (IC RC) or
• B. Individual licensed as either a professional
  counselor, clinical social worker, registered
  nurse, psychiatric clinical nurse specialist, a
  psychiatric nurse practitioner, marriage and
  family therapist, clinical psychologist, or
  physician who is qualified by training
  experience in addiction counseling or
• C. Individual licensed as a substance abuse
  treatment practitioner by the Virginia Board of
  Counseling or
• D. Individual certified as either a clinical
  supervisor by the Substance Abuse Certification
  Alliance of Virginia or as a Master Addiction
  Counselor by the National Association of
  Alcoholism and Drug Abuse Counselors or from the
  International Certification and Reciprocity
  Consortium/Alcohol and Other Drug Abuse, Inc (IC
  RC) or
• E. Individual with completed Masters level
  training in psychology, social work, counseling,
  or rehabilitation and is certified as a Master
  Addiction Counselor by the National Association
  of Alcoholism and Drug Abuse Counselors or from
  the International Certification and Reciprocity
  Consortium/Alcohol and Other Drug Abuse, Inc (IC
  RC) or

41
Qualified Substance Abuse Professional (QSAP)
contd

• F. Individual with bachelors degree and
  certified as a Substance Abuse Counselor by the
  Board of Counseling or
• G. Individual with bachelors degree and
  certified as an Addictions Counselor by the
  Substance Abuse Certification Alliance of
  Virginia or
• H. Individual with bachelors degree and
  certified as a Level II Addiction Counselor by
  the National Association of Alcoholism and Drug
  Abuse Counselors or from the International
  Certification and Reciprocity Consortium/Alcohol
  and Other Drug Abuse, Inc (IC RC)
• Bachelor level staff with certifications require
  supervision every two weeks by professional
  meeting one of the criteria specified in A
  through E.

42
Paraprofessional Qualifications

• Paraprofessionals must meet the following
  qualifications
• An associate's degree in human service at one
  year experience providing direct services to
  persons with a diagnosis of mental illness /
  substance abuse or
• Associate's or higher degree, in unrelated field
  three years experience providing direct
  services to persons with a diagnosis of mental
  illness / substance abuse or

43
Paraprofessional Qualifications contd

• Minimum of 90 hours classroom training in
  behavioral health 12 weeks experience under
  direct personal supervision of a QSAP providing
  services or
• College credits earned towards bachelor's degree
  in a human service field equivalent to
  associate's degree one year's clinical
  experience or
• Licensure by the Commonwealth as a practical
  nurse with one year of clinical experience
• Paraprofessionals must participate in clinical
  supervision with a QSAP at least twice a month.
• Experience may include supervised internships,
  practicums and field experience.

44
Substance Abuse Case Management (H0006)

• Provider must be licensed by DMHMRSAS as a
  provider of substance abuse case management
  services
• May bill Medicaid for substance abuse case
  management only when the services are provided by
  professionals who meet the following criteria
• a. Bachelors degree one year of SA related
  clinical experience providing direct services
• b. Licensure RN or LPN one year of SA related
  clinical experience

45
Substance Abuse Case Management (H0006)

• Service Definition
• SA Case Management assists with accessing needed
  substance abuse, medical, psychiatric, social,
  educational, vocational services other supports
  essential to meeting basic needs
• If client has co-occurring mental health and SA
  disorders, the case manager should address both
  the MH SA disorders
• Only one type of case management may be billed at
  one time

46
SA Case ManagementEligibility Criteria

• Recipient must meet DSM-IV-TR diagnostic criteria
  for Axis I substance-related disorder. Nicotine
  or caffeine abuse or dependence are not covered
• Must require case management based on an
  appropriate assessment and supporting
  documentation
• Must be an active client, -- requires regular
  direct or client-related contacts, communication
  or activity

47
SA Case Management Required Activities

• Initial Assessment
• ISP fully completed within 30 days of service
  initiation
• ISP modified as necessary, reviewed every three
  months, and rewritten annually
• Mandatory monthly CM contact / activity to
  include as needed
• Linking the individual to services
• Assisting directly for the purpose of locating,
  developing, or obtaining needed services and
  resources

48
SA Case Management Required Activities contd

• Coordinating services and treatment planning.
• Enhancing community integration
• Making collateral contacts with significant
  others.
• Monitoring service delivery through contacts with
  service providers as well as periodic site visits
  and home visits.
• Education and counseling
• A face-to-face contact must be made at least once
  every 90-day period.

49
SA Case Management Documentation Requirements

• Documentation that choice of a provider has been
  offered
• Release forms must be completed for the release
  of any information
• Initial comprehensive assessment / reassessments
  
• ISPs which demonstrates the recipient was
  involved in and sign the plan
• ISPs from other providers rendering services to
  the recipient are in the record

50
SA Case Management Documentation Requirements
contd

• Revisions / updates of the ISP whenever the
  amount, type, or frequency of services rendered
  changes
• Documented quarterly reviews of the ISP to
  determine if service goals / objectives are being
  met
• Documentation that notes all contacts made by the
  case manager

51
SA Case Management Service Units Limitations

• The billing unit for case management is 15
  minutes Maximum service limit for substance abuse
  case management services is 52 hours per year.
• Billing submitted for case management only when
  direct or client-related contacts, activity, or
  communications occur.
• Reimbursement provided only for active case
  management
• No other type of case management may be billed
  concurrently with substance abuse case management

52
SA Case Management Service Units Limitations
contd

• Reimbursement for CM services for individuals in
  an Institution for Mental Disease (IMD) is not
  allowed
• Discharge planning CM services may be billed
• -- Three conditions must be met
• The services may not duplicate the services of
  the institutional discharge planner,
• Are limited to one month of service, 30 days
  prior to discharge from the facility
• May be billed for no more than two
  non-consecutive pre-discharge periods in 12
  months

53
Substance Abuse Crisis Intervention (H0050)

• SA Crisis Intervention service agencys must be
  licensed as a Substance Abuse Outpatient Service
  provider by DMHMRSAS
• May bill Medicaid for SA Crisis Intervention when
  services are provided by professionals who meet
  the following criteria
• QSAP
• Certified Pre-screener,
• Paraprofessional (safety monitoring only)

54
Substance Abuse Crisis Intervention

• Service Definition
• Crisis Intervention services are SA treatment
  interventions available 24/7 to provide
  assistance to individuals experiencing acute
  dysfunction related to substance use which
  requires immediate clinical attention
• The objectives are
• To prevent exacerbation of a condition
• To prevent injury to the recipient or others
  and
• To provide treatment in the least restrictive
  setting.

55
SA Crisis Intervention Eligibility Criteria

• SA Crisis Intervention services are provided
  following a marked reduction in the recipients
  psychiatric, adaptive, or behavioral functioning
  or an extreme increase in personal distress
• If an individual has co-occurring mental health
  and substance use disorders, integrated treatment
  for both disorders is allowed within Substance
  Abuse Crisis Intervention Services

56
SA Crisis Intervention Required Activities

• QSAP or Certified CSB Pre-screener must complete
  document face-to-face assessment of the crisis
  situation provide short-term counseling provide
  access to further immediate assessment and
  follow-up and link to ongoing care
• Must be documentation of immediate substance
  abuse treatment
• Services may be provided outside of the clinic
  and billed if it is clinically or
  programmatically appropriate

57
SA Crisis Intervention Required Activities contd

• Monitoring F to F support may be provided by a
  QSAP, a certified prescreener, or a
  paraprofessional to ensure the clients safety
• ISP is not required for newly admitted recipients
• ISP prepared by a Certified Pre-screener or QSAP
  by the fourth face-to-face
• If case management is being provided, there must
  be coordination with the case management agency
• If other clinic services are billed while
  receiving C I services, documentation must
  clearly support separation of services with
  distinct treatment goals

58
SA Crisis Intervention Service Units
Limitations

• A unit of service is 15 minutes of SA CI. Maximum
  of 720 units can be provided annually.
• Face-to-face contact with the recipient must
  occur during crisis episode to bill for SA CI
  services.
• Reimbursement is provided for short-term crisis
  counseling contacts scheduled within 30-day
  period from the time of the first F-to-F crisis
  contact.
• Staff travel time is excluded from billable time.
• Medicaid cannot be billed for SA CI services for
  recipient under Emergency Custody Orders or
  Temporary Detention Orders

59
Substance Abuse Intensive Outpatient (H2016)

• SA IOP service agencys must be licensed as a
  Substance Abuse Outpatient Service provider by
  DMHMRSAS.
• May bill Medicaid for SA IOP when services are
  provided by professionals who meet the following
  criteria
• QSAP (Bachelors or Masters)
• Paraprofessional

60
Substance Abuse Intensive Outpatient

• Service Definition
• Intensive outpatient services is provision of
  coordinated, intensive, comprehensive,
  multidisciplinary treatment through a combination
  of diagnostic, medical, psychiatric, and
  psychosocial interventions. Intensive outpatient
  services include assessment, treatment planning,
  counseling, medication monitoring, behavior
  management, and psycho education

61
SA Intensive Outpatient Eligibility Criteria

• Recipient must meet DSM-IV-TR diagnostic criteria
  for Axis I substance-related disorder. Nicotine
  or caffeine abuse or dependence are not covered.
  American Society of Addiction Medicine (ASAM)
  criteria will be used to determine the
  appropriate level of treatment
• If individual has co-occurring mental health /
  substance use disorders, integrated treatment for
  both disorders is allowed within SA IOP treatment

62
SA Intensive Outpatient Required Activities

• Program must operate minimum of two continuous
  hours in a 24-hour period
• QSAP must perform a F-to-F evaluation /
  diagnostic assessment authorize services prior
  to initiation. If service is longer than 90
  continuous days, QSAP must perform a face-to-face
  evaluation and re-authorize service
• ISP must be completed by a QSAP within 30 days of
  service initiation
• Individual, group counseling, family therapy,
  occupational recreational therapy must be
  provided by at least a QSAP
• QSAP or paraprofessional may provide education
  about the effects of alcohol and other drugs on
  the physical, emotional and social functioning of
  the individual, relapse prevention, occupational
  and recreational activities

63
SA Intensive Outpatient Required Activities
contd

• QSAP must be onsite when the paraprofessional is
  providing service
• QSAP must supervise the paraprofessional at least
  twice a month
• Paraprofessionals who do not meet experience
  requirements may provide services for Medicaid
  reimbursement if they are working directly with a
  qualified paraprofessional on-site supervised
  by a QSAP
• Progress notes must be completed when services
  are delivered
• If case management is being provided, there must
  be coordination with the case management agency

64
SA Intensive Outpatient Service Units
Limitations

• Service is provided to recipients who do not
  require inpatient, residential, or day treatment
  services, but require more than outpatient
  services
• Individuals must be discharged when other less
  intensive services may achieve stabilization
• One unit of service is 15 minutes. Reimbursement
  is based on the level of professional providing
  the service
• Minimum number of service hours per week is 4
  hours with a maximum of 19 hours per week
• The maximum annual limit is 600 hours
• Intensive outpatient services may not be provided
  concurrently with day treatment services or
  opioid treatment services
• Staff travel time is excluded

65
Substance Abuse Day Treatment (H0047)

• SA Day Treatment agencys must be licensed as a
  provider of Day Treatment service by DMHMRSAS
• May bill Medicaid for SA IOP when services are
  provided by professionals who meet the following
  criteria
• QSAP (Bachelors or Masters)
• Paraprofessional

66
SA Day Treatment

• Service Definition
• Day treatment is the provision of coordinated,
  intensive, comprehensive, and multidisciplinary
  treatment through a combination of diagnostic,
  medical, psychiatric, and psychosocial
  interventions. Day Treatment services include
  assessment, treatment planning, counseling,
  medication monitoring, behavior management, and
  psycho education

67
SA Day Treatment Eligibility Criteria

• Recipient must meet DSM-IV-TR diagnostic criteria
  for Axis I substance-related disorder. Nicotine
  or caffeine abuse or dependence are not covered.
  American Society of Addiction Medicine (ASAM)
  criteria will be used to determine the
  appropriate level of treatment
• If individual has co-occurring mental health /
  substance use disorders, integrated treatment for
  both disorders is allowed within SA Day Treatment

68
SA Day Treatment Required Activities

• Program must operate minimum of two continuous
  hours in a 24-hour period
• QSAP must perform a F-to-F evaluation /
  diagnostic assessment authorize services prior
  to initiation. If service is longer than 90
  continuous days, QSAP must perform a face-to-face
  evaluation and re-authorize services
• ISP must be completed by a QSAP within 30 days of
  service initiation
• Individual, group counseling, family therapy,
  occupational recreational therapy must be
  provided by at least a QSAP
• QSAP or paraprofessional may provide education
  about the effects of alcohol and other drugs on
  the physical, emotional and social functioning of
  the individual, relapse prevention, occupational
  and recreational activities

69
SA Day Treatment Required Activities contd

• QSAP must be onsite when the paraprofessional is
  providing services
• QSAP must supervise the paraprofessional at least
  twice a month
• Paraprofessionals who do not meet experience
  requirements may provide services for Medicaid
  reimbursement if they are working directly with a
  qualified paraprofessional on-site supervised
  by a QSAP
• Progress notes must be completed when services
  are delivered
• If case management is being provided, there must
  be coordination with the case management agency

70
SA Day TreatmentService Units Limitations

• Service is provided to recipients who do not
  require inpatient or residential services
• Individuals must be discharged when other less
  intensive services may achieve stabilization
• One unit of service is 15 minutes. Reimbursement
  is based on the level of professional providing
  the service.
• Minimum number of service hours per week is 20
  hours with a maximum of 30 hours per week.
• Maximum annual limit is 1,300 hours
• Staff travel time is excluded

71
Opioid Treatment (H0020)

• Opioid Treatment agencys must be licensed as a
  provider of Opioid Treatment services by DMHMRSAS
• May bill Medicaid for Opioid Treatment when
  services are provided by professionals who meet
  the following criteria
• QSAP (Bachelors or Masters)
• Paraprofessional

72
Opioid Treatment

• Service Definition
• Opioid Treatment services provide an
  intervention strategy that combines substance
  abuse treatment with the administering or
  dispensing of opioid agonist treatment
  medication. An individual-specific,
  physician-ordered dose of medication is
  administered or dispensed either for
  detoxification or maintenance treatment.
• Treatment is provided in daily sessions

73
Opioid Treatment Eligibility Criteria

• Recipient must meet DSM-IV-TR diagnostic criteria
  for Axis I substance-related disorder. Nicotine
  or caffeine abuse or dependence are not covered.
  American Society of Addiction Medicine (ASAM)
  criteria will be used to determine the
  appropriate level of treatment
• If individual has co-occurring mental health /
  substance use disorders, integrated treatment for
  both disorders is allowed within the Opioid
  Treatment

74
Opioid Treatment Required Activities

• QSAP must perform a F-to-F evaluation /
  diagnostic assessment authorize services prior
  to initiation. If service is longer than 90
  continuous days, QSAP must perform a face-to-face
  evaluation and re-authorize services
• ISP must be completed by a QSAP within 30 days of
  service initiation
• Individual, group counseling, family therapy,
  occupational recreational therapy must be
  provided by at least a QSAP
• QSAP or paraprofessional may provide education
  about the effects of alcohol and other drugs on
  the physical, emotional and social functioning of
  the individual, relapse prevention, occupational
  and recreational activities

75
Opioid Treatment Required Activities contd

• QSAP must be onsite when the paraprofessional is
  providing services
• QSAP must supervise the paraprofessional at least
  twice a month
• Paraprofessionals who do not meet experience
  requirements may provide services for Medicaid
  reimbursement if they are working directly with a
  qualified paraprofessional on-site supervised
  by a QSAP
• Progress notes must be completed when services
  are delivered
• If case management is being provided, there must
  be coordination with the case management agency

76
Opioid Treatment Service Units Limitations

• Individuals must be discharged when other less
  intensive services may achieve stabilization
• One unit of service is 15 minutes. Reimbursement
  is based on the level of professional providing
  the service.
• The maximum annual limit is 600 hours.
• Staff travel time is excluded
• Providers may submit reimbursement claims for
  opioids which are administered to persons
  receiving Opioid Treatment Services. Providers
  may enroll as a Pharmacy provider
• Pharmacies would bill as point of sale

77
Utilization Review For Substance Abuse Services
78

• Federal regulations require that DMAS review and
  evaluate the services provided through the
  Medicaid program

79
Purpose of Utilization Review

• Ensure clinical necessity and that an
  appropriate provider delivers the services

Ensure the provision of quality health care
Ensure program integrity
80
General UR Facts

• Reviews will be initiated on a regular basis to
  meet federal requirements or by referrals and
  complaints from agencies or individuals
• Reviews may be unannounced
• Review may be based on a random
• sample from the provider's Medicaid
• billing
• A targeted review may be conducted if an
  excessive number of exceptions or problems are
  identified

81
Your UR Site Visit

• Record Review will include
• Request to review billing
• records in a central
• location
• The Review may include
• Observation of service delivery
• Face-to-face/telephone
• interviews
• Review of staff qualifications

82
UR staff check that

• Services provided meet all requirements defined
  and described in the DMAS Service manual
• Services billed match documented delivered care
• Services do not exceed specific service
  limitations

83
The UR Golden Rule

• Delivered services as documented are consistent
  with the recipients Individual Service Plan,
  submitted invoices and specified service
  limitations

84
UR Problem Areas

• For All Services
• Missing or incomplete assessments
• Assessments completed after service initiation
• Checklists not corroborated with supporting
  documentation
• ISPs missing or late
• ISPs not individualized and specific
• Missing re-authorizations for services

85
UR Problems contd

• Documentation not correlating with time / units
  billed or needs on ISP
• Missing documentation / lack of description of
  billable services
• Signatures and credentials (qualifications) not
  documented

• Documentation not completed within appropriate
  timeframe
• Billing for services beyond specific limitations
• Documentation not legible

86
Reporting Process

• After the review, UR staff will conduct an exit
  conference to describe findings and provide
  technical assistance

Written report follows within 2 weeks
Providers may request a reconsideration
87
Overpayments required when

• Medicaid billed contrary to regulation or statute
• Provider fails to maintain any record or adequate
  documentation to support the claim
• Provider bills for an unnecessary service
• Error found in computing billing amounts

88
Reconsideration of Adverse Actions

• Process has 3 phases-
• Written response and reconsideration to
  preliminary findings (30 days to submit
  information)
• The informal conference (30 days to request
  informal conference)
• The formal evidentiary hearing
• (30 days to request formal hearing)

89
Repayment of Identified Overpayments

• Section 32.1-325.1 of the Code of Virginia,
  mandates that DMAS collect identified
  overpayments
• Repayment must be made on demand unless a
  repayment schedule is agreed upon by DMAS
• When a lump sum cash payment is not made,
  interest will be added on the declining balance
  at the statutory rate

90
DMAS Contact Information

• DMAS SA Phone Line for PA questions
• 804-371-2645
• Catherine Hancock
• Catherine.hancock_at_dmas.virginia.gov
• 804-225-4272
• William OBier
• William.obier_at_dmas.virginia.gov
• 804-225-4050

91
Thank You!
www.dmas.virginia.gov