TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Fast-Track Regulation

Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-420, 12VAC30-50-430, 12VAC30-50-491).

12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-143, 12VAC30-60-185).

Statutory Authority: § 32.1-325 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: December 18, 2024.

Effective Date: January 2, 2025.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Richmond, VA 23219, telephone (804) 371-0552, FAX (804) 786-1680, or email meredith.lee@dmas.virginia.gov.

Basis: Section 32.1-325 of the Code of Virginia grants the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The federal Mental Health Parity regulation can be found at 42 CFR 438.910(b)(1).

Purpose: This action protects the public health, welfare, and safety by ensuring compliance with federal laws and regulations and aligning with mental health case management requirements to ensure that Virginia Medicaid is able to continue to receive the federal match for the program and to ensure clarity for providers and members.

Rationale for Using Fast-Track Rulemaking Process: This action is expected to be noncontroversial because DMAS is aligning its regulations with the Medicaid Mental Health Parity Rule and clarifying existing DMAS practices. There are no reductions in services associated with this action.

Substance: The amendments remove the limit on substance use case management for individuals in institutions for mental diseases (IMDs) to comply with the Medicaid Mental Health Parity Rule. This action aligns DMAS regulations with 42 CFR 441.18(a)(8)(vii) and documents DMAS existing practices by specifying that reimbursement is allowed for mental health and substance use case management services for Medicaid-eligible individuals who are in institutions, provided that (i) the case management services do not duplicate other services provided by the institution and (ii) the case management services are provided to the individual 30 calendar days prior to discharge. For individuals 22 to 64 years of age, the amendments clarify that case management services rendered in the same month as the admission to an IMD are reimbursable as long as the case management services are rendered prior to the date of the admission or past the date of discharge from the IMD.

Other amendments include (i) clarifying individual service plan review timeframes and grace periods, (ii) clarifying that certified substance abuse counselor-supervisees can bill for substance use case management services, and (iii) documenting existing DMAS practices.

Issues: The primary advantage to the public is that removing the limit on substance use case management for individuals in IMDs ensures that individuals can receive appropriate levels and frequency of service. The primary advantage to DMAS and the Commonwealth is that this action aligns the state regulations with 42 CFR 411.18(a)(8)(vii) and appropriately documents and clarifies current DMAS practices. There are no disadvantages to the public, the agency, the Commonwealth, or the regulated community.

Department of Planning and Budget Economic Impact Analysis:

The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. The director of the Department of Medical Assistance Services (DMAS), on behalf of the Board of Medical Assistance Services, proposes to align the regulatory text with the federal rules and to make several clarifying changes to reflect current reimbursement practices.

Background. On March 30, 2016, the Centers for Medicare and Medicaid Services (CMS) issued the Medicaid Mental Health Parity Rule.² The overall objective of the parity rule is to ensure that accessing mental health and substance use disorder services is no more difficult than accessing medical or surgical services. However, the parity rule in 42 CFR 438.910(b)(1) created a contradiction with the current language in DMAS regulations. Under the current language, substance use case management services are not reimbursable for individuals while they are residing in institutions, including institutions for mental disease (IMD).³ Although DMAS reports that this limitation has never been enforced, it must be stricken from the regulation for consistency with the federal rule. Additionally, the proposed action clarifies that reimbursement is allowed pursuant to 42 CFR 441.18(a)(8)(vii) for substance use and mental health case management services for Medicaid-eligible individuals who are in institutions, provided two conditions are met.⁴ The two conditions are that (ii) the case management services may not duplicate other services provided by the institution and (ii) the case management services must be provided to the individual 30 calendar days prior to discharge. For individuals 22 to 64 years of age, case management services that are rendered during the same month as the admission to an IMD are reimbursable as long as the case management services are rendered prior to the date of the admission or past the date of discharge from the IMD. According to DMAS, these changes clarify existing reimbursement practices. The remaining changes are also clarifications regarding the Individual Service Plan review timeframes and grace periods and billing by Certified Substance Abuse Counselor-Supervisees. These changes do not affect the services provided or eligibility.

Estimated Benefits and Costs. All of the proposed changes are consistent with reimbursement rules that have been followed in practice even before the federal parity rule became effective in 2016. Thus, no significant economic impact is expected other than improving the consistency of the regulatory text with federal rules and text accuracy and clarity.

Businesses and Other Entities Affected. The proposed action improves consistency, accuracy, and clarity of the regulatory text for the public and Medicaid recipients and providers. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁵ An adverse impact is indicated if there is any increase in net cost or reduction in net revenue for any entity, even if the benefits exceed the costs for all entities combined. As noted above, the proposed action is expected to have no significant economic impact other than improving the consistency of the regulatory text with federal rules and text accuracy and clarity. Thus, no adverse impact is indicated.

Small Businesses⁶ Affected.⁷ The proposed action would not adversely affect small businesses.

Localities⁸ Affected.⁹ No adverse impact on localities is indicated.

Projected Impact on Employment. The proposed action does not affect employment.

Effects on the Use and Value of Private Property. No impact on the use and value of private property or real estate development costs is expected.

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¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² https://www.govinfo.gov/content/pkg/FR-2016-03-30/pdf/2016-06876.pdf.

³ The exception to this limitation on reimbursement is that substance use case management may be reimbursed during the month prior to discharge to allow for discharge planning. This exception is limited to two one-month periods during a 12-month period.

⁴ These conditions do not apply to individuals between the ages of 22 and 64 years who are served in IMD, and individuals of any age who are inmates of public institutions.

⁵ Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁶ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁷ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁸ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁹ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Department of Medical Assistance Services has reviewed the economic impact analysis prepared by the Department of Planning and Budget and raises no issues with this analysis.

Summary:

The amendments (i) remove the limit for individuals in institutions for mental diseases (IMDs) to only be able to receive substance use case management at the time of discharge twice in a 12-month period to comply with the Medicaid Mental Health Parity Rule issued by the Centers for Medicare and Medicaid Services on March 20, 2016; (ii) align the regulation with 42 CFR 441.18(a)(8)(vii) and document Department of Medical Assistance Services (DMAS) practice by specifying that reimbursement is allowed, provided two conditions are met, for substance use and mental health case management services for Medicaid-eligible individuals who are in institutions, with the exception of individuals between 22 and 64 years of age who are served in IMDs and individuals of any age who are inmates of public institutions; (iii) clarify individual service plan review timeframes and grace periods, including revising the time period for grace periods from "months" to "calendar days"; (iv) clarify that certified substance abuse counselor-supervisees can bill for substance use case management services to document DMAS current practices, rather than changes in practice; and (v) consolidate 12VAC30-60-185 B and C to remove duplicative language.

12VAC30-50-420. Case management services for seriously mentally ill adults and emotionally disturbed children.

A. Target Group: group for case management services for seriously mentally ill adults and emotionally disturbed children. The Medicaid eligible Medicaid-eligible individual shall meet the DBHDS definition for "serious mental illness," pursuant to 42 CFR 483.102(b)(1) or "serious emotional disturbance in children and adolescents." pursuant to Appendix A of the Department of Behavioral Health and Developmental Services (DBHDS) Core Services Taxonomy 7.3.

1. An active client for case management shall mean an individual for whom there is a plan of care in effect which that requires regular direct or client-related contacts or communication or activity with the client, family, service providers, significant others, and others, including at least one face-to-face contact every 90 days. Billing can be submitted for an active client only for months in which direct or client-related contacts, activity, or communications occur. Authorization is required for Medicaid reimbursement.

2. There shall be no maximum service limits for case management services. Case In accordance with 42 CFR 441.18(a)(8)(vii), reimbursement is allowed for case management shall not be billed for services for Medicaid-eligible individuals who are in institutions for mental disease, with the exception of individuals who are 22 years of age to 64 years of age and are served in institutions of mental diseases (IMDs) and individuals of any age who are inmates of public institutions. An IMD is a facility that is primarily engaged in the treatment of mental illness and has more than 16 beds in accordance with § 1905(i) of the Social Security Act.

3. For individuals who are 22 years of age to 64 years of age, services rendered during the same month as the admission to the IMD are reimbursable as long as the service was rendered prior to the date of the admission.

4. Case management services for individuals who are younger than 22 years of age or older than 64 years of age in an IMD may be billed 30 calendar days prior to discharge as long as the case management services do not duplicate other services provided by the institution.

B. Services for seriously mentally ill adults and emotionally disturbed children will be provided to the entire state.

C. Comparability of Services: case management services for seriously mentally ill adults and emotionally disturbed children. Services are not comparable in amount, duration, and or scope. Authority of § 1915(g)(1) of the Social Security Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Social Security Act.

D. Definition of Services: Mental health case management services for seriously mentally ill adults and emotionally disturbed children. Case management services assist individual children and adults, in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs. Services to be provided include:

1. Assessment and planning services, to include developing an Individual Service Plan individual service plan (ISP) (does not include performing medical and psychiatric assessment but does include referral for such assessment);

2. Linking the individual to services and supports specified in the individualized service plan ISP;

3. Assisting the individual directly for the purpose of locating, developing, or obtaining needed services and resources;

4. Coordinating services and service planning with other agencies and providers involved with the individual;

5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and use vocational, civic, and recreational services;

6. Making collateral contacts with the individuals' individual's significant others to promote implementation of the service plan and community adjustment;

7. Follow-up and monitoring to assess ongoing progress and to ensure services are delivered; and

8. Education and counseling which that guides the client and develops a supportive relationship that promotes the service plan.

E. Qualifications of Providers: providers of case management services for seriously mentally ill adults and emotionally disturbed children.

1. Services are not comparable in amount, duration, and or scope. Authority of § 1915(g)(1) of the Social Security Act is invoked to limit case management providers for individuals with mental retardation a developmental disability and individuals with serious/chronic serious or chronic mental illness to the Community Services Boards only to enable them to provide services to serious/chronically mentally ill or mentally retarded individuals with a developmental disability or serious or chronic mental illness without regard to the requirements of § 1902(a)(10)(B) of the Social Security Act.

2. To qualify as a provider of services through DMAS for rehabilitative mental health case management, the provider of the services must meet certain the following criteria. These criteria shall be:

a. The provider must have the administrative and financial management capacity to meet state and federal requirements;

b. The provider must have the ability to document and maintain individual case records in accordance with state and federal requirements;

c. The services shall be in accordance with the Virginia Comprehensive State Plan for Mental Health, Mental Retardation and Substance Abuse Services;

d. The provider must be licensed as a provider of case management services by the DBHDS; and

e. Persons providing case management services must have knowledge of:

(1) Services, systems, and programs available in the community, including primary health care, support services, eligibility criteria and intake processes, generic community resources, and mental health, mental retardation developmental disability, and substance abuse treatment programs;

(2) The nature of serious mental illness, mental retardation developmental disability, and substance abuse depending on the population served, including clinical and developmental issues;

(3) Different types of assessments, including functional assessments, and their uses in service planning;

(4) Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning, and service coordination;

(5) The service planning process and major components of a service plan;

(6) The use of medications in the care or treatment of the population served; and

(7) All applicable federal and state laws, state regulations, and local ordinances.;

f. Persons providing case management services must have skills in:

(1) Identifying and documenting an individual's needs for resources, services, and other supports;

(2) Using information from assessments, evaluations, observation, and interviews to develop individual service plans ISPs;

(3) Identifying services and resources within the community and established service system to meet the individual's needs; and documenting how resources, services, and natural supports, such as family, can be utilized to achieve an individual's personal habilitative/rehabilitative habilitative or rehabilitative and life goals; and

(4) Coordinating the provision of services by public and private providers.; and

g. Persons providing case management services must have abilities to:

(1) Work as team members, maintaining effective inter- inter-agency and intra-agency working relationships;

(2) Work independently, performing position duties under general supervision; and

(3) Engage in and sustain ongoing relationships with individuals receiving services.

3. Providers may bill Medicaid for mental health case management only when the services are provided by qualified mental health case managers.

F. The state assures ensures that the provision of case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Social Security Act.

1. Eligible recipients will have free choice of the providers of case management services.

2. Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Payment for case management services under the plan shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

H. Case management services may not be billed concurrently with intensive community treatment services, treatment foster care case management services, or intensive in-home services for children and adolescents.

12VAC30-50-430. Case management services for youth at risk of serious emotional disturbance.

A. Target group: Medicaid eligible for case management services for youth at risk of serious emotional disturbance. Medicaid-eligible individuals who meet the DBHDS definition of youth at risk of serious emotional disturbance pursuant to Appendix A of the Department of Behavioral Health and Developmental Services (DBHDS) Core Services Taxonomy 7.3.

1. An active client shall mean an individual for whom there is a plan of care in effect which that requires regular direct or client-related contacts or communication or activity with the client, family, service providers, significant others, and others, including at least one face-to-face contact every 90-days 90 days. Billing can be submitted for an active client only for months in which direct or client-related contacts, activity, or communications occur. Authorization is required for Medicaid reimbursement.

2. There shall be no maximum service limits for case management services. Case management services must not be billed for individuals who are in institutions for mental disease diseases, except for the 30 calendar days prior to discharge as long as the case management services do not duplicate other services provided by the institution. Case management services must not be billed for individuals who are inmates of public institutions.

B. Services for youth at risk of serious emotional disturbance will be provided in the entire state.

C. Comparability of services: case management services for youth at risk of serious emotional disturbance. Services are not comparable in amount, duration, and or scope. Authority of § 1915(g)(1) of the Social Security Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Social Security Act.

D. Definition of services: Mental health case management services for youth at risk of serious emotional disturbance. Case management services assist youth at risk of serious emotional disturbance in accessing needed medical, psychiatric, social, educational, vocational, and other supports essential to meeting basic needs. Services to be provided include:

1. Assessment and planning services, to include developing an Individual Service Plan individual service plan (ISP);

2. Linking the individual directly to services and supports specified in the treatment/services treatment or services plan;

3. Assisting the individual directly for the purpose of locating, developing, or obtaining needed service and resources;

4. Coordinating services and service planning with other agencies and providers involved with the individual;

5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and use vocational, civic, and recreational services;

6. Making collateral contacts, which are nontherapy contacts, with an individual's significant others to promote treatment and/or or community adjustment;

7. Following up and monitoring to assess ongoing progress and ensuring services are delivered; and

8. Education Providing education and counseling which that guides the client and develops a supportive relationship that promotes the service plan.

E. Qualifications of providers of case management services for youth at risk of serious emotional disturbance.

1. Services are not comparable in amount, duration, and or scope. Authority of § 1915(g)(1) of the Social Security Act is invoked to limit case management providers, to the community services boards only, to enable them to provide services to serious/chronically mentally ill or mentally retarded individuals with a developmental disability or serious or chronic mental illness without regard to the requirements of § 1902(a)(10)(B) of the Social Security Act. To qualify as a provider of case management services to youth at risk of serious emotional disturbance, the provider of the services must meet the following criteria:

a. The provider must meet state and federal requirements regarding its capacity for administrative and financial management;

b. The provider must document and maintain individual case records in accordance with state and federal requirements;

c. The provider must provide services in accordance with the Virginia Comprehensive State Plan for Mental Health, Mental Retardation and Substance Abuse Services;

d. The provider must be licensed as a provider of case management services by the DBHDS; and

e. Persons providing case management services must have knowledge of:

(1) Services, systems, and programs available in the community, including primary health care, support services, eligibility criteria, and intake processes, generic community resources, and mental health, mental retardation developmental disability, and substance abuse treatment programs;

(2) The nature of serious mental illness, mental retardation and/or developmental disability, or substance abuse depending on the population served, including clinical and developmental issues;

(3) Different types of assessments, including functional assessments, and their uses in service planning;

(4) Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning, and service coordination;

(5) The service planning process and major components of a service plan;

(6) The use of medications in the care or treatment of the population served; and

(7) All applicable federal and state laws, state regulations, and local ordinances.;

f. Persons providing case management services must have skills in:

(1) Identifying and documenting an individual's need for resources, services, and other supports;

(2) Using information from assessments, evaluations, observation, and interviews to develop individual service plans ISPs;

(3) Identifying services and resources within the community and established service system to meet the individual's needs; and documenting how resources, services, and natural supports, such as family, can be utilized to achieve an individual's personal habilitative/rehabilitative habilitative or rehabilitative and life goals; and

(4) Coordinating the provision of services by diverse public and private providers.; and

g. Persons providing case management services must have abilities to:

(1) Work as team members, maintaining effective inter- inter-agency and intra-agency working relationships;

(2) Work independently performing position duties under general supervision; and

(3) Engage in and sustain ongoing relationships with individuals receiving services.

F. Providers may bill Medicaid for mental health case management to youth at risk of serious emotional disturbance only when the services are provided by qualified mental health case managers.

G. The state assures ensures that the provision of case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Social Security Act.

1. Eligible recipients will have free choice of the providers of case management services.

2. Eligible recipients will have free choice of the providers of other medical care under the plan.

H. Payment for case management services under the plan must not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

I. Case management may not be billed concurrently with intensive community treatment services, treatment foster care case management services, or intensive in-home services for children and adolescents.

12VAC30-50-491. Substance use case management services for individuals who have a primary diagnosis of substance use disorder.

A. Target group: for substance use case management services for individuals who have a primary diagnosis of substance use disorder.

1. The Medicaid eligible Medicaid-eligible individual shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for a substance use disorder. Tobacco-related disorders or caffeine-related disorders and nonsubstance-related disorders shall not be covered. Substance use case management shall include an active individual service plan (ISP) that requires a minimum of two substance use case management service activities each month and at least one face-to-face contact with the individual at least every 90 calendar days.

2. There shall be no maximum service limits for case management services.

3. In accordance with 42 CFR 441.18(a)(8)(vii), reimbursement is allowed for case management services for Medicaid-eligible individuals who are in institutions, with the exception of individuals who are 22 years of age to 64 years of age and served in institutions of mental diseases (IMDs) and individuals of any age who are inmates of public institutions. An IMD is a facility that is primarily engaged in the treatment of mental illness and has more than 16 beds.

4. For individuals who are 22 years of age to 64 years of age, services rendered during the same month as the admission to the IMD are reimbursable as long as the service was rendered prior to the date of the admission.

5. Case management services for individuals who are younger than 22 years of age or older than 64 years of age in an IMD may be billed 30 calendar days prior to discharge as long as the case management services do not duplicate other services provided by the institution.

B. Services for substance use case management for individuals who have a primary diagnosis of substance use disorder will be provided to the entire state.

C. Comparability of services: for substance use case management services for individuals who have a primary diagnosis of substance use disorder. Services are not comparable in amount, duration, and or scope. Authority of § 1915(g)(1) of the Social Security Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Social Security Act.

D. Definition of substance use case management services: for individuals who have a primary diagnosis of substance use disorder. Substance use case management services assist individuals and their family members in accessing needed medical, psychiatric, psychological, social, educational, vocational, recovery, and other supports essential to meeting the individual's basic needs. Substance use case management is reimbursable on a monthly basis only when the minimum substance use case management service activities are met. Substance use case management services are not reimbursable for individuals while they are residing in institutions, including institutions for mental disease, except that substance use case management may be reimbursed during the month prior to discharge to allow for discharge planning. This is limited to two one-month periods during a 12-month period. Tobacco-related disorders or caffeine-related disorders and nonsubstance-related disorders shall not be covered. Substance use case management does not include maintaining service waiting lists or periodically contacting or tracking individuals to determine potential service needs. Substance use case management services are to be person centered, individualized, and culturally and linguistically appropriate to meet the individual's and family member's needs.

Substance use case management service activities to be provided shall include:

1. Assessing needs and planning services to include developing a substance use case management individual service plan (ISP). The ISP shall utilize accepted placement criteria and shall be fully completed within 30 calendar days of initiation of service;

2. Enhancing community integration through increased opportunities for community access and involvement and enhancing community living skills to promote community adjustment, including, to the maximum extent possible, the use of local community resources available to the general public;

3. Making collateral contacts with the individual's significant others with properly authorized releases to promote implementation of the individual's ISP and his the individual's community adjustment;

4. Linking the individual to those community supports that are most likely to promote the personal habilitative or rehabilitative, recovery, and life goals of the individual as developed in the ISP;

5. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits;

6. Assuring Ensuring the coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems, such as local health and social services departments;

7. Monitoring service delivery through contacts with individuals receiving services and service providers and site and home visits to assess the quality of care and satisfaction of the individual;

8. Providing follow-up instruction, education, and counseling to guide the individual and develop a supportive relationship that promotes the ISP;

9. Advocating for individuals the individual in response to their the individual's changing needs, based on changes in the ISP;

10. Planning for transitions in the individual's life;

11. Knowing and monitoring the individual's health status, any medical condition, and medications and potential side effects and assisting the individual in accessing primary care and other medical services, as needed; and

12. Understanding the capabilities of services to meet the individual's identified needs and preferences and to serve the individual without placing the individual, other participants, or staff at risk of serious harm.

E. Qualifications of providers: of substance use case management services for individuals who have a primary diagnosis of substance use disorder.

1. The provider of substance use case management services must meet the following criteria:

a. The enrolled provider must have the administrative and financial management capacity to meet state and federal requirements;

b. The enrolled provider must have the ability to document and maintain individual case records in accordance with state and federal requirements; and

c. The enrolled provider must be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) as a provider of substance abuse case management services.

2. Providers may bill Medicaid for substance use case management only when the services are provided by a professional or professionals who meet meets at least one of the following criteria:

a. At least a bachelor's degree in one of the following fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, or human services counseling) and has at least either (i) one year of substance use related use-related direct experience providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience working with individuals with co-occurring diagnoses of substance use disorder and mental illness;

b. Licensure by the Commonwealth as a registered nurse with (i) at least one year of substance use related use-related direct experience providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience working with individuals with co-occurring diagnoses of substance use disorder and mental illness; or

c. Certification as a Board of Counseling Certified Substance Abuse Counselor (CSAC), CSAC-Supervisee, or CSAC-Assistant under clinical supervision as defined in 18VAC115-30-10 et seq.

F. The state assures ensures that the provision of substance use case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Social Security Act.

1. Eligible individuals shall have free choice of the providers of substance use case management services.

2. Eligible individuals shall have free choice of the providers of other services under the plan.

G. Payment for substance use case management or substance use care coordination services under the Plan plan does not duplicate payments for other case management made to public agencies or private entities under other Title XIX program authorities for this same purpose.

H. The state assures ensures that the individual will not be compelled to receive substance use case management services, condition receipt of case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management services.

I. The state assures ensures that providers of substance use case management service services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

J. The state assures ensures that substance use case management is only provided by and reimbursed to community case management providers.

K. The state assures ensures that substance use case management does not include the following:

1. The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred.

2. Activities for which an individual may be eligible, that are integral to the administration of another nonmedical program, except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903(c) of the Social Security Act.

12VAC30-60-143. Mental health services utilization criteria; definitions.

A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context indicates otherwise:

"Certified prescreener" means an employee of either the local community services board or behavioral health authority, or its designee, who is skilled in the assessment and treatment of mental illness and who has completed a certification program approved by the Department of Behavioral Health and Developmental Services (DBHDS).

"Certified prescreener assessment" means an assessment for crisis intervention and crisis stabilization completed by a certified prescreener that meets the elements of a comprehensive needs assessment.

"Comprehensive needs assessment" means the same as defined in 12VAC30-50-130 and also includes individuals who are older than 21 years of age.

"Emergency services" means unscheduled and sometimes scheduled crisis intervention, stabilization, acute psychiatric inpatient services, and referral assistance provided over the telephone or face-to-face if indicated, and available 24 hours a day, seven days per week.

"Licensed mental health professional" or "LMHP" means the same as defined in 12VAC30-50-130 12VAC30-105-20.

"LMHP-resident" or "LMHP-R" means the same as defined in 12VAC30-50-130.

"LMHP-resident in psychology" or "LMHP-RP" means the same as defined in 12VAC30-50-130.

"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as defined in 12VAC30-50-130.

"Qualified mental health professional-adult" or "QMHP-A" means the same as defined in 12VAC30-50-130 12VAC35-105-20.

"Qualified mental health professional-child" or "QMHP-C" means the same as defined in 12VAC30-50-130.

"Qualified mental health professional-eligible" or "QMHP-E" means the same as defined in 12VAC35-105-20 12VAC30-50-130.

"Qualified paraprofessional in mental health" or "QPPMH" means the same as the term is defined in 12VAC35-105-20.

B. Utilization reviews shall include determinations that providers meet the following requirements:

1. The provider shall meet the federal and state requirements for administrative and financial management capacity. The provider shall obtain, prior to the delivery of services, and shall maintain and update periodically as the Department of Medical Assistance Services (DMAS) or its contractor requires, a current provider enrollment agreement for each Medicaid service that the provider offers. DMAS shall not reimburse providers who do not enter into a provider enrollment agreement for a service prior to offering that service.

2. The provider shall document and maintain individual case records in accordance with state and federal requirements.

3. The provider shall ensure eligible individuals have free choice of providers of mental health services and other medical care under the Individual Service Plan individual service plan (ISP).

4. Providers shall comply with DMAS marketing requirements as set out in 12VAC30-130-2000. Providers that DMAS determines have violated these marketing requirements shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E. Providers whose contracts are terminated shall be afforded the right of appeal pursuant to the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).

5. If an individual receiving community mental health rehabilitative services is also receiving case management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider shall collaborate with the case manager by notifying the case manager of the provision of community mental health rehabilitative services and sending monthly updates on the individual's treatment status. A discharge summary shall be sent to the care coordinator/case manager care coordinator or case manager within 30 calendar days of the discontinuation of services. Service providers and case managers who are using the same electronic health record for the individual shall meet requirements for delivery of the notification, monthly updates, and discharge summary upon entry of this documentation into the electronic health record.

6. The provider shall determine who the primary care provider is and inform him the primary care provider of the individual's receipt of community mental health rehabilitative services. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.

7. Prior to admission, an appropriate comprehensive needs assessment shall be conducted by the licensed mental health professional (LMHP), LMHP-S, LMHP-R, or LMHP-RP. The comprehensive needs assessment shall include documented history of the severity, intensity, and duration of mental health care problems and issues. and all of the following elements: (i) the presenting issue or reason for referral; (ii) mental health history or history of hospitalizations; (iii) previous interventions by providers and timeframes and response to treatment; (iv) medical profile; (v) developmental history, including history of abuse, if appropriate; (vi) educational or vocational status; (vii) current living situation and family history and relationships; (viii) legal status,; (ix) drug and alcohol profile; (x) resources and strengths; (xi) mental status exam and profile; (xii) diagnosis; (xiii) professional summary and clinical formulation; (xiv) recommended care and treatment goals; and (xv) the dated signature of the LMHP, LMHP-supervisee LMHP-S, LMHP-resident LMHP-R, or LMHP-RP.

a. A single comprehensive needs assessment shall be used to document the medical necessity for one or more community mental health rehabilitative service provided by the same DBHDS licensed DBHDS-licensed agency.

b. The comprehensive needs assessment shall be: completed face to face and signed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S; include all required elements as defined in 12VAC30-50-130; describe how each recommended community mental health rehabilitative service is medically necessary; and be reviewed and updated at a minimum of annually or as the individual's needs change.

c. The comprehensive needs assessment shall be reviewed and updated by an LMHP, LMHP-R, LMHP-RP, or LMHP-S within 31 days if there is a clinical indication based on the medical, psychiatric, or behavioral symptoms of the individual.

d. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall conduct an annual face to face face-to-face review and update of the comprehensive needs assessment that includes: a review of the comprehensive needs assessment; any necessary updates to the 15 required elements of the comprehensive needs assessment to reflect the individual's current level of functioning; an updated description of how the individual meets medical necessity criteria for all recommended services; and a contemporaneously dated signature of the LMHP, LMHP-R, LMHP-RP, or LMHP-S.

e. The comprehensive needs assessment is outdated if any of the following occurs: an LMHP, LMHP-R, LMHP-RP, or LMHP-S has not completed the annual review and update; within the past 31 calendar days, the provider has not provided a community mental health rehabilitative service or a case management activity (as defined in 12VAC30-50-420 or 12VAC30-50-430) as recommended by the comprehensive needs assessment,; or, within the past 31 days, the comprehensive needs assessment has not been updated to reflect a change in the individual's current level of functioning.

f. If the comprehensive needs assessment is outdated, a new comprehensive needs assessment is required prior to resuming a community mental health rehabilitative service that lapsed for more than 31 calendar days. If the comprehensive needs update is not outdated, it must, at a minimum, be updated to document the medical necessity for a community mental health rehabilitative service that lapsed for more than 31 calendar days.

g. Providers shall only bill under the community mental health rehabilitative service assessment codes for the initial comprehensive needs assessment and for comprehensive needs assessments that replace an outdated assessment. Providers of multiple community mental health rehabilitative services shall only bill one community mental health rehabilitative service assessment code per individual.

h. Claims for services that are based upon comprehensive needs assessments that are incomplete, outdated, or missing shall not be reimbursed.

i. For crisis intervention and crisis stabilization services, a certified prescreener assessment may be used in place of the comprehensive needs assessment.

8. The provider shall include the individual and the family/caregiver family or caregiver, as may be appropriate, in the development of the ISP. To the extent that the individual's condition requires assistance for participation, assistance shall be provided. The ISP shall be updated annually or as the needs and progress of the individual changes. An ISP that is not updated either annually or as the treatment interventions based on the needs and progress of the individual change shall be considered outdated. An ISP that does not include all required elements specified in 12VAC30-50-226 shall be considered incomplete. Claims for services that are based upon ISPs that are incomplete, outdated, or missing shall not be reimbursed. All ISPs shall be completed, signed, and contemporaneously dated by the appropriate professional for the service, who is preparing the ISP within a maximum of 30 days of the date of the completed assessment unless otherwise specified. A youth's ISP shall also be signed by the parent or legal guardian and the adult individual shall sign his own. If the individual is unwilling to sign the ISP, then the service provider shall document the clinical or other reasons why the individual was not able or willing to sign the ISP. Signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP.

a. Every three months, the appropriate professional for the service shall review the ISP, modify the ISP as appropriate, and update the ISP, and all of these activities shall occur with the individual in a manner in which the individual may participate in the process. The ISP shall be rewritten at least annually.

b. The goals, objectives, and strategies of the ISP shall be updated to reflect any change or changes in the individual's progress and treatment needs as well as any newly-identified newly identified problems.

c. Documentation of ISP review shall be added to the individual's medical record no later than 15 days from the calendar date of the review as evidenced by the dated signatures of the appropriate professional for the service and the individual.

9. Progress notes shall include, at a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units or hours required to deliver the service. The content of each progress note shall corroborate the units or hours billed. Progress notes shall be documented for each service that is billed.

10. Services described in this section shall be rendered consistent with the definitions, service limits, and requirements described in this section and in 12VAC30-50-226.

C. Day treatment/partial treatment or partial hospitalization services shall be provided following a comprehensive needs assessment completed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S. An ISP, as defined in 12VAC30-50-226, shall be fully completed, signed, and dated by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, the QMHP-A, QMHP-E, or QMHP-C and reviewed or approved by the LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 days of service initiation.

1. The enrolled provider of day treatment/partial treatment or partial hospitalization shall be licensed by DBHDS as providers a provider of day treatment services.

2. Services shall only be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S, a QMHP-A, a QMHP-C, a QMHP-E, or a qualified paraprofessional under the supervision of a QMHP-A, QMHP-C, QMHP-E, or an LMHP, LMHP-R, LMHP-RP, or LMHP-S.

3. The program shall operate a minimum of two continuous hours in a 24-hour period.

4. Individuals shall be discharged from this service when other less intensive services may achieve or maintain psychiatric stabilization.

D. Psychosocial rehabilitation services shall be provided to those individuals who have experienced long-term or repeated psychiatric hospitalization, or who experience difficulty in activities of daily living and interpersonal skills, or whose support system is limited or nonexistent, or who are unable to function in the community without intensive intervention or when long-term services are needed to maintain the individual in the community.

1. Psychosocial rehabilitation services shall be provided following a comprehensive needs assessment that clearly documents the need for services. The comprehensive needs assessment shall be completed by either an LMHP, LMHP-R, LMHP-RP, or LMHP-S. An ISP shall be completed by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, or the QMHP-A, QMHP-E, or QMHP-C and be reviewed or approved by either an LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 calendar days of service initiation. At least every three months, the LMHP, LMHP-R, LMHP-RP, LMHP-S, the QMHP-A, QMHP-C, or QMHP-E must review, modify as appropriate, and update the ISP.

2. Psychosocial rehabilitation services of any individual that continue for more than six months shall be reviewed by an LMHP, LMHP-R, LMHP-RP, or LMHP-S who shall document the continued need for the service. The ISP shall be rewritten at least annually.

3. The enrolled provider of psychosocial rehabilitation services shall be licensed by DBHDS as a provider of psychosocial rehabilitation services.

4. Psychosocial rehabilitation services may be provided by an LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, QMHP-E, or a qualified paraprofessional under the supervision of a QMHP-A, a QMHP-C, a QMHP-E, or an LMHP, LMHP-R, LMHP-RP, or LMHP-S.

5. The program shall operate a minimum of two continuous hours in a 24-hour period.

6. Time allocated for field trips may be used to calculate time and units if the goal is to provide training in an integrated setting, and to increase the individual's understanding or ability to access community resources.

E. Initiation of crisis intervention services shall be indicated following a comprehensive needs assessment completed by an LMHP, LMHP-R, LMHP-RP, or LMHP-S, or a certified prescreener assessment that documents a marked reduction in the individual's psychiatric, adaptive, or behavioral functioning or an extreme increase in personal distress. In order to receive reimbursement, providers shall register this service with DMAS or its contractor within one business day of the completion of the comprehensive needs assessment to avoid duplication of services and to ensure informed care coordination.

1. The crisis intervention services provider shall be licensed as a provider of emergency services by DBHDS.

2. Client-related activities provided in association with a face-to-face contact are reimbursable.

3. An individual service plan (ISP) shall not be required for newly admitted individuals to receive this service. Inclusion of crisis intervention as a service on the ISP shall not be required for the service to be provided on an emergency basis.

4. For individuals receiving scheduled, short-term counseling as part of the crisis intervention service, an ISP shall be developed or revised to reflect the short-term counseling goals by the fourth face-to-face contact.

5. Reimbursement shall be provided for short-term crisis counseling contacts occurring within a 30-day period from the time of the first face-to-face crisis contact. There are no restrictions (regarding number of contacts or a given time period to be covered) for reimbursement for unscheduled crisis contacts.

6. Crisis intervention services may be provided to eligible individuals outside of the clinic and reimbursed, provided the provision of out-of-clinic services is clinically or programmatically appropriate. Travel by staff to provide out-of-clinic services shall not be reimbursable. Crisis intervention may involve contacts with the family or significant others. If other clinic services are billed at the same time as crisis intervention, documentation must clearly support the separation of the services with distinct treatment goals.

7. An LMHP, LMHP-R, LMHP-RP, or LMHP-S shall conduct a comprehensive needs assessment, or a certified prescreener shall conduct a face-to-face comprehensive assessment that documents the need for and the anticipated duration of the crisis service.

8. Crisis intervention shall be provided by either an LMHP, LMHP-R, LMHP-RP, LMHP-S, or a certified prescreener.

9. For an admission to a freestanding inpatient psychiatric facility for individuals younger than age 21 years of age, federal regulations (42 CFR 441.152) require certification of the admission by an independent team. The independent team must include mental health professionals, including a physician. These preadmission screenings cannot be billed unless the requirement for an independent team certification, with a physician's signature, is met.

10. Services shall be documented through daily notes and a daily log of time spent in the delivery of services.

F. Case management services pursuant to 12VAC30-50-420 (Case management services for seriously mentally ill adults and emotionally disturbed children) or 12VAC30-50-430 (Case management services for youth at risk of serious emotional disturbance).

1. Reimbursement shall be provided only for "active" case management clients, as defined. An active client for case management shall mean an individual for whom there is an ISP in effect that requires regular direct or client-related contacts or activity or communication with the individuals or families, significant others, service providers, and others, including a minimum of one face-to-face individual contact within a 90-day period. Billing can be submitted only for months in which direct or client-related contacts, activity, or communications occur.

2. The Medicaid eligible Medicaid-eligible individual shall meet the DBHDS criteria of serious mental illness, serious emotional disturbance in children and adolescents, or youth at risk of serious emotional disturbance.

3. There shall be no maximum service limits for case management services. Case management shall not be billed for persons in institutions for mental disease.

4. Reimbursement is allowed for case management services for Medicaid-eligible individuals who are in institutions pursuant to 12VAC30-50-420 and 12VAC30-50-430.

5. The ISP shall document the need for case management and be fully completed within 30 calendar days of initiation of the service. The case manager shall review the ISP at least every three months 90 calendar days. The review will be due by the last day of the third month following the month in which the last review was completed. A grace period will be granted up to the last day of the fourth month following the month of the last review. When the review was completed in a grace period, the next subsequent review shall be scheduled three months from the month the review was due and not the date of actual review. 5. Such reviews shall be documented in the individual's medical record.

6. Reviews will be due by the end of the month following the 90th calendar day from when the last review was completed. If needed, a grace period will be granted up to the last day of the next month. If the review was completed in a grace period, the next subsequent review shall be required within 90 calendar days from when the review was due and not the date of the actual review.

7. The ISP shall also be updated at least annually.

6. 8. The provider of case management services shall be licensed by DBHDS as a provider of case management services.

G. Intensive community treatment (ICT).

1. A comprehensive needs assessment that documents eligibility and the need for this service shall be completed by either the LMHP, LMHP-R, LMHP-RP, or LMHP-S prior to the initiation of services. The comprehensive needs assessment documentation shall be maintained in the individual's records.

2. An individual service plan ISP, based on the needs as determined by the comprehensive needs assessment, must be initiated at the time of admission and must be fully developed by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E and approved by the LMHP, LMHP-R, LMHP-RP, or LMHP-S within 30 days of the initiation of services.

3. ICT may be billed if the individual is brought to the facility by ICT staff to see the psychiatrist. Documentation must be present in the individual's record to support this intervention.

4. The enrolled ICT provider shall be licensed by the DBHDS as a provider of intensive community services or as a program of assertive community treatment, and must provide and make available emergency services 24-hours 24 hours per day, seven days per week, 365 days per year, either directly or on call.

5. ICT services must be documented through a daily log of time spent in the delivery of services and a description of the activities/services activities or services provided. There must also be at least a weekly note documenting progress or lack of progress toward goals and objectives as outlined on the ISP.

H. Crisis stabilization services.

1. This service shall be initiated following a face-to-face comprehensive needs assessment by either an LMHP, LMHP-R, LMHP-RP, or LMHP-S, or an assessment completed by a certified prescreener that documents the need for crisis stabilization services.

2. In order to receive reimbursement, providers shall register this service with DMAS or its contractor within one business day of the completion of the provider's assessment to avoid duplication of services and to ensure informed care coordination.

3. The Individual Service Plan (ISP) must be developed or revised within three calendar days of admission to this service. The LMHP, LMHP-R, LMHP-RP, LMHP-S, certified prescreener, QMHP-A, QMHP-C, or QMHP-E shall develop the ISP.

4. Room and board, custodial care, and general supervision are not components of this service.

5. Clinic option services are not billable at the same time crisis stabilization services are provided, with the exception of clinic visits for medication management. Medication management visits may be billed at the same time that crisis stabilization services are provided, but documentation must clearly support the separation of the services with distinct treatment goals.

6. Individuals qualifying for this service must demonstrate a clinical necessity for the service arising from a condition due to an acute crisis of a psychiatric nature which puts the individual at risk of psychiatric hospitalization.

7. Providers of residential crisis stabilization shall be licensed by DBHDS as providers of residential or nonresidential crisis stabilization services. Providers of community-based crisis stabilization shall be licensed by DBHDS as providers of mental health nonresidential crisis stabilization.

I. Mental health skill-building services (MHSS) as defined in 12VAC30-50-226 B 6.

1. At admission, an appropriate face-to-face comprehensive needs assessment must be conducted, documented, signed, and dated by the LMHP, LMHP-R, LMHP-RP, or LMHP-S. Providers shall be reimbursed one unit for each intake utilizing the appropriate billing code. Services of any individual that continue more than six months shall be reviewed by the LMHP, LMHP-R, LMHP-RP, or LMHP-S who shall document the continued need for the service in the individual's medical record.

2. The primary mental health diagnosis shall be documented as part of the comprehensive needs assessment by the LMHP, LMHP-R, LMHP-RP, or LMHP-S performing the comprehensive needs assessment.

3. The LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E shall complete, sign, and date the ISP within 30 days of the admission to this service. The ISP shall include documentation of how many days per week and how many hours per week are required to carry out the goals in the ISP. The total time billed for the week shall not exceed the frequency established in the individual's ISP. The ISP shall indicate the dated signature of the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E and the individual. The ISP shall indicate the specific training and services to be provided, the goals and objectives to be accomplished, and criteria for discharge as part of a discharge plan that includes the projected length of service. If the individual refuses to sign the ISP, this shall be noted in the individual's medical record documentation.

4. Every three months, the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E shall review with the individual in a manner in which he the individual may participate with the process, modify as appropriate, and update the ISP. The ISP must be rewritten at least annually.

a. The goals, objectives, and strategies of the ISP shall be updated to reflect any change or changes in the individual's progress and treatment needs as well as any newly identified problem.

b. Documentation of this review shall be added to the individual's medical record no later than 15 calendar days from the date of the review, as evidenced by the dated signatures of the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E and the individual.

5. The ISP shall include discharge goals that will enable the individual to achieve and maintain community stability and independence. The ISP shall fully support the need for interventions over the length of the period of service requested from the service authorization contractor.

6. Reauthorizations for service shall only be granted if the provider demonstrates to either DMAS or the service authorization contractor that the individual is benefitting from the service as evidenced by updates and modifications to the ISP that demonstrate progress toward ISP goals and objectives.

7. If the provider knows or has reason to know of the individual's nonadherence to a regimen of prescribed medication, medication adherence shall be a goal in the individual's ISP. If the care is delivered by the qualified paraprofessional, the supervising LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C shall be informed of any nonadherence to the prescribed medication regimen. The LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C shall coordinate care with the prescribing physician regarding any concerns about medication nonadherence (, provided that the individual has consented to such sharing of information). The provider shall document the following minimum elements of the contact between the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C and the prescribing physician:

a. Name and title of caller;

b. Name and title of professional who was called;

c. Name of organization that for which the prescribing professional works for;

d. Date and time of call;

e. Reason for the care coordination call;

f. Description of the medication regimen issue or issues to be discussed; and

g. Whether or not there was a resolution of the medication regimen issue or issues.

8. Discharge summaries shall be prepared by providers a provider for all of the individuals in their the provider's care. Documentation of prior psychiatric services history shall be maintained in the individual's mental health skill-building services medical record.

9. Documentation of prior psychiatric services history shall be maintained in the individual's mental health skill-building services medical record. The provider shall document evidence of the individual's prior psychiatric services history, as required by 12VAC30-50-226 B 6 b (3) and 12VAC30-50-226 B 6 c (4), by contacting the prior provider or providers of such health care services after obtaining written consent from the individual. Documentation of telephone contacts with the prior provider shall include the following minimum elements:

a. Name and title of caller;

b. Name and title of professional who was called;

c. Name of organization that for which the professional works for;

d. Date and time of call;

e. Specific placement provided;

f. Type of treatment previously provided;

g. Name of treatment provider; and

h. Dates of previous treatment.

Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.

10. The provider shall document evidence of the psychiatric medication history, as required by 12VAC30-50-226 B 6 b (4) and 12VAC30-50-226 B 6 c (5), by maintaining a photocopy of prescription information from a prescription bottle or by contacting the current or previous prescribing provider of health care services or pharmacy after obtaining written consent from the individual. Prescription lists or medical records, including discharge summaries, obtained from the pharmacy or current or previous prescribing provider of health care services that contain (i) the name of the prescribing physician, (ii) the name of the medication with dosage and frequency, and (iii) the date of the prescription shall be sufficient to meet these criteria. Family member statements shall not suffice to meet this requirement.

11. In the absence of such documentation, the current provider shall document all contacts (i.e., telephone, faxes, electronic communication) with the pharmacy or provider of health care services with the following minimum elements: (i) name and title of caller, (ii) name and title of prior professional who was called, (iii) name of organization that for whom the professional works for, (iv) date and time of call, (v) specific prescription confirmed, (vi) name of prescribing physician, (vii) name of medication, and (viii) date of prescription.

12. Only direct face-to-face contacts and services to an individual shall be reimbursable.

13. Any services provided to the individual that are strictly academic in nature shall not be billable. These include, but are not limited to, such basic educational programs as instruction or tutoring in reading, science, mathematics, or GED.

14. Any services provided to individuals that are strictly vocational in nature shall not be billable. However, support activities and activities directly related to assisting an individual to cope with a mental illness to the degree necessary to develop appropriate behaviors for operating in an overall work environment shall be billable.

15. Room and board, custodial care, and general supervision are not components of this service.

16. Provider qualifications. The enrolled provider of mental health skill-building services must be licensed by DBHDS as a provider of mental health community support ( as defined in 12VAC35-105-20). Individuals employed or contracted by the provider to provide mental health skill-building services must have training in the characteristics of mental illness and appropriate interventions, training strategies, and support methods for persons with mental illness and functional limitations. Mental health skill-building services shall be provided by either an LMHP, LMHP-R, LMHP-RP, LMHP-S, a QMHP-A, a QMHP-C, a QMHP-E, or a QPPMH. The LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, or QMHP-C will supervise the care weekly if delivered by the QMHP-E or QPPMH. Documentation of supervision shall be maintained in the mental health skill-building services record.

17. Mental health skill-building services shall be documented through a daily log of time involved in the delivery of services and a minimum of a weekly summary note of services provided. The provider shall clearly document services provided to detail what occurred during the entire amount of the time billed.

18. If mental health skill-building services are provided in a therapeutic group home or assisted living facility, effective July 1, 2014, there shall be a yearly limit of up to 416 units per fiscal year and a weekly limit of up to eight units per week, with at least half of each week's services provided outside of the group home or assisted living facility. There shall be a daily limit of a maximum of two units. Prior to July 1, 2014, the previous limits shall apply. DMAS or its contractor may authorize additional units of mental health skill-building services that exceed this limit based on documented medical necessity. The ISP shall not include activities that contradict or duplicate those in the treatment plan established by the group home or assisted living facility. The provider shall attempt to coordinate mental health skill-building services with the treatment plan established by the group home or assisted living facility and shall document all coordination activities in the medical record.

19. Limits and exclusions.

a. Therapeutic group home and assisted living facility providers shall not serve as the mental health skill-building services provider for individuals residing in the provider's respective facility. Individuals residing in facilities may, however, receive MHSS from another MHSS agency not affiliated with the owner of the facility in which they reside.

b. Mental health skill-building services shall not be reimbursed for individuals who are receiving in-home residential services or congregate residential services through the Intellectual Disability Waiver or Individual and Family Developmental Disabilities Support Waiver.

c. Mental health skill-building services shall not be reimbursed for individuals who are also receiving independent living skills services, the Department of Social Services independent living program (22VAC40-151), independent living services (22VAC40-131 and 22VAC40-151), or independent living arrangement (22VAC40-131) or any Comprehensive Services Act-funded independent living skills programs.

d. Mental health skill-building services shall not be available to individuals who are receiving treatment foster care (12VAC30-130-900 et seq.).

e. Mental health skill-building services shall not be available to individuals who reside in intermediate care facilities for individuals with intellectual disabilities or hospitals.

f. Mental health skill-building services shall not be available to individuals who reside in nursing facilities, except for up to 60 days prior to discharge. If the individual has not been discharged from the nursing facility during the 60-day period of services, mental health skill-building services shall be terminated and no further service authorizations shall be available to the individual unless a provider can demonstrate and document that mental health skill-building services are necessary. Such documentation shall include facts demonstrating a change in the individual's circumstances and a new plan for discharge requiring up to 60 days of mental health skill-building services.

g. Mental health skill-building services shall not be available for residents of psychiatric residential treatment centers, except for the assessment code H0032 (modifier U8) in the seven days immediately prior to discharge.

h. Mental health skill-building services shall not be reimbursed if personal care services or attendant care services are being received simultaneously, unless justification is provided regarding why this is necessary in the individual's mental health skill-building services record. Medical record documentation shall fully substantiate the need for services when personal care or attendant care services are being provided. This applies to individuals who are receiving additional services through the Intellectual Disability Waiver (12VAC30-120-1000 et seq.), Individual and Family Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.) Developmental Disability Waivers (12VAC30-122), the Elderly or Disabled with Consumer Direction Commonwealth Coordinated Care Plus Waiver (12VAC30-120-900 et seq.), and EPSDT services (12VAC30-50-130).

i. Mental health skill-building services shall not be duplicative of other services. Providers have a responsibility to ensure that if an individual is receiving additional therapeutic services that there will be coordination of services by either the LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP-A, QMHP-C, or QMHP-E to avoid duplication of services.

j. Individuals who have organic disorders, such as delirium, dementia, or other cognitive disorders not elsewhere classified, will be prohibited from receiving mental health skill-building services unless their physicians issue the individual's physician issues a signed and dated statement indicating that the individuals can individual could benefit from this service.

k. Individuals who are not diagnosed with a serious mental health disorder but who have personality disorders or other mental health disorders, or both, that may lead to chronic disability, will not be excluded from the mental health skill-building services eligibility criteria, provided that the individual has a primary mental health diagnosis from the list included in 12VAC30-50-226 B 6 b (1) or 12VAC30-50-226 B 6 c (2) and that the provider can document and describe how the individual is expected to actively participate in and benefit from mental health support services.

J. Except as noted in subdivision I 18 of this section and in 12VAC30-50-226 B 6 e, the limits described in this section and in 12VAC30-50-226 shall apply to all service authorization requests submitted to either DMAS or the behavioral health services agency as of July 27, 2016. As of July 27, 2016, all annual limits, weekly limits, daily limits, and reimbursement for services shall apply to all services described in 12VAC30-50-226 regardless of the date upon which service authorization was obtained.

12VAC30-60-185. Utilization review of substance use case management.

A. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:

"Face-to-face" means the same as that term is defined in 12VAC30-130-5020.

"Individual service plan" or "ISP" means the same as the term is defined in 12VAC30-130-5020.

"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes and are part of the minimum documentation requirements that convey the individual's status, staff intervention, and as appropriate, the individual's progress or lack of progress toward goals and objectives in the ISP. The progress notes shall also include, at a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units or hours required to deliver the service. The content of each progress note shall corroborate the time or units billed for each rendered service. Progress notes shall be documented for each service that is billed.

"Register" or "registration" means notifying the Department of Medical Assistance Services (DMAS) or its contractor that an individual will be receiving services that do not require service authorization, such as outpatient services for substance use disorders or substance use case management.

B. Utilization review: substance use case management services.

1. The Medicaid-enrolled individual shall have a substance use disorder diagnosis based on nationally recognized criteria. Tobacco-related disorders or caffeine-related disorders and non-substance-related disorders shall not be covered.

2. Reimbursement shall be provided only for "active" case management. An active client for substance use case management shall mean an individual for whom there is a current substance use ISP in effect that requires a minimum of two distinct substance use case management activities being performed each calendar month and, at a minimum, one face-to-face client contact at least every 90-calendar-day period.

3. Billing can be submitted for an active recipient only for months in which a minimum of two distinct substance use case management activities are performed.

4. An ISP shall be completed within 30 calendar days of initiation of this service with the individual in a person-centered manner and shall document the need for active substance use case management before such case management services can be billed. The ISP shall require a minimum of two distinct substance use case management activities being performed each calendar month and a minimum of one face-to-face client contact at least every 90 calendar days. The substance use case manager shall review the ISP with the individual at least every 90 calendar days for the purpose of evaluating and updating the individual's progress toward meeting the individualized service plan objectives. Such reviews shall be documented in the individual's medical record.

5. Reviews will be due by the end of month following the 90th calendar day from when the last review was completed. If needed, a grace period will be granted up to the last day of the next month. If the review was completed in a grace period, the next subsequent review shall be required within 90 calendar days from when the review was due and not the date of the actual review.

6. The ISP shall be reviewed with the individual present, and the outcome of the review shall be documented in the individual's medical record.

C. Utilization review: substance use case management services.

1. Utilization review general requirements. Utilization reviews shall be conducted by DMAS or its designated contractor. Reimbursement shall be provided only when there is an active ISP, a minimum of two distinct substance use case management activities are performed each calendar month, and there is a minimum of one face-to-face client contact at least every 90-calendar-day period. Billing can be submitted only for months in which a minimum of two distinct substance use case management activities are performed within the calendar month.

2. 7. In order to receive reimbursement, providers shall register this service with the managed care organization or the DMAS contractor, as required, within one business day of service initiation to avoid duplication of services and to ensure informed and seamless care coordination between substance use treatment and substance use case management providers.

3. The Medicaid-eligible individual shall meet the nationally recognized criteria for a substance use disorder with the exception of tobacco-related disorders or caffeine-related disorders and non-substance-related disorders.

4. Substance use case management shall not be billed for individuals in institutions for mental disease, except during the month prior to discharge to allow for discharge planning, limited to two months within a 12-month period. 8. Substance use case management shall not be billed concurrently with any other type of Medicaid reimbursed case management and care coordination.

5. The ISP, as defined in 12VAC30-130-5020, shall document the need for substance use case management and be fully completed within 30 calendar days of initiation of the service, and the substance use case manager shall review the ISP at least every 90 calendar days. Such reviews shall be documented in the individual's medical record. If needed, a grace period will be granted following the date of the last review. When the review is completed in a grace period, the next subsequent review shall be scheduled 90 calendar days from the date the review was initially due and not the date of actual review.

6. 9. The ISP shall be updated and documented in the individual's medical record at least annually and as an individual's needs change.

7. 10. The provider of substance use case management services shall be licensed by the Department of Behavioral Health and Developmental Services as a provider of substance use case management and credentialed by the DMAS contractor or the managed care organization as a provider of substance use case management services.

8. 11. Progress notes, as defined in subsection A of this section, shall be required to disclose the extent of services provided and corroborate the units billed.

12. Reimbursement is allowed for case management services for Medicaid-eligible individuals who are in institutions pursuant to 12VAC30-50-491.

13. Utilization reviews shall be conducted by DMAS or its designated contractor.