General Reimbursement Requirements
Medicaid parts (aka "rules") followed by Behavioral Health Providers.
What are Rule 140 and Rule 132
Double points for either identifying the full title/part OR identifying what is covered in each: What are Title 89 Part 140 (medical payment) and Title 59 Part 132 (community mental health services program)
Services must be _____________necessary to be reimbursed.
What is Medically necessary / Medical necessity
This service includes communication with other professionals about a client, including contact with staff at other agencies and internal staffings and shift changes.
What is client-centered consultation (aka client-centered consultation case management)
Billable or non-billable: Preparation required in order to perform a billable activity (e.g. gathering files, planning activities)
What is Non-billable
This ties together the assessment, diagnosis, treatment plan, progress notes (service documentation) in the client's record.
What is the Golden Thread
True or False: Services must be delivered by qualifications (credentials) specified by Medicaid rules.
What is: True
Double points for identifying the credential you qualify as
Type of diagnosis required for medical necessity.
what is: billable DSM5 / mental health / behavioral health
This service includes psychoeducation to build skills as identified in the service definition. These are activities the staff does with the client so they can perform the activity independently in the future.
What is community support (individual)
Billable or non-billable: services delivered in a manner consistent with policies/procedures of Medicaid (IM+CANS completed appropriately and signed by LPHA within necessary timelines)
What is Billable.
If a service is done outside of these policies/procedures it is non-billable.
Services performed by only an MHP or higher credential (name at least 2)
What is therapy/counseling, IATP, crisis intervention
Aside from a few exceptions, these 2 basic requirements must be done for services to be reimbursed. (name at least 1 of 2)
What is: the IM+CANS must be completed (and signed by an LPHA) and documented services must be included on the client's treatment plan
True or False: Client does not need to have an impact on functioning for medical necessity.
What is False. The client must have impaired level of functioning in areas such as self-care, work, family living, social relationships and treatment is expected to help increase level of functioning.
This service includes activities done for a client in order to assist the client, including coordination of services. The client can be present, but does not need to be present.
What is mental health case management
Billable or non-billable: unavoidable down-time (waiting for an individual prior to a billable activity)
What is non-billable.
Billable or non-billable: the provider is attempting to bill for more than one staff person per service delivered on an individual claim.
What is non-billable.
Double points: Billable or non-billable: a service completed in less than 7.5 minutes. Answer: what is non-billable.
These are 3 services are exceptions to the basic reimbursement requirements (i.e. they do not need a completed IM+CANS or to be listed on the treatment plan)
What is: IATP service, Crisis services, Mental Health Case Management (for up to 30 days prior to IM+CANS completion)
Medically necessary services are meant to: Reduce _______disability and restore __________
What are: blank one: mental; blank two: functioning
Double points for naming the other things that make a service medically necessary:
1. Recommended by LPHA
2. Are consistent with service limitations, utilization controls, and prior authorizations established by the Department (i.e. provided according to generally accepted standards of practice, clinically appropriate, not provided out of convenience, not more costly than alternative services providing similar outcomes)
This service is delivered to support the completion of the IM+CANS. It includes gathering information from the client and collaterals, including reviewing documentation to collect information for the assessment.
What is integrated assessment and treatment planning (IATP)
Billable or non-billable: activities required to complete a billable service after the service episode is concluded (completing case notes/documentation, returning files, etc.)
What is non-billable
Documentation rules for your agency.
Game facilitator know the answer needed.
Final Jeopardy: Defines the limits of what a professional can do within their field. Ensures that professionals practice within their competencies, thereby protecting the practitioner and client.
what is: Scope of Practice