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Charlene Toten, Division Director


Mental Health Services offered by Medicaid include:

Acute Freestanding Psychiatric Facilities
–provide acute services for children under 21, with an average length of stay of 7-10 days. Prior authorization is required.

Therapeutic and Evaluative Mental Health Services for Children–provide the Expanded Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program for children under 21 years of age, which includes therapeutic and evaluative services. All services must be medically necessary and require prior authorization from the Division of Medicaid. Service standards apply but can be over-ridden.

Clinical Record Review Process
       Therapeutic Services Record Review
       Psychological Evaluation Record Review
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Billing Guidelines for Therapeutic & Evaluative Mental Health Services for Children
(Formerly Billing Guidelines for Community-Based Mental Health Services)

Community Mental Health Center Services – mental health services provided for children and adults by one of the regional Community Mental Health Centers or Community Services Division of a State Hospital.
Community Mental Health Center Billing Guidelines

Federally Qualified Health Center and Rural Health Clinics–provide mental health services in the community, but are based on visits. Each person is allowed a medical visit and a separate mental health visit. All visits count against the service limits for adults. Children under the age of 21 may receive more visits, if medically necessary, with prior authorization.

Geriatric Psychiatric services are NOT covered.

Inpatient Detox for Chemical Dependency –limited to detoxification. Medicaid does not cover alcohol and drug treatment; however, with a primary mental health diagnosis, the rules for psychiatric units apply.

Intellectual Disabilities/Developmental Disabilities
The ID/DD Waiver provides services to individuals who, but for the provision of home and community-based services, would require placement in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). Individuals in this program must qualify for one of the following eligibility categories: SSI, TANF, Disabled Child Living at Home, or income up to 300% of the SSI Federal Benefit Rate. The ID/DD waiver is administered by the Department of Mental Health, Bureau of Intellectual and Developmental Disabilities. The Department, through its regional centers, provides support coordination and, through an assessment process, makes referrals for the following services: Behavior Support, Day Services-Adult, Home and Community Supports, Occupational Therapy, Physical Therapy, Speech Therapy, Supervised Living, Community Respite, Host Homes, Crisis Support, Crisis Intervention, In-Home Nursing Respite, Support Living, Transition Assistance, Support Coordination, Supported Employment, Prevocational Services, Job Discovery and Specialized Medical Supplies.   

                                    Approved 1915(c) Waiver (full content)

                                    ID/DD Waiver On-Site Compliance Review Process

                                                    DMH Document Review 

                                                     Regional Center Document Review 

                                                    Staff Interviews

                                                     Home Visit

                                                    Individual Record Review 

                                    ID/DD Brochure

                                    ID/DD Waiver Fee Schedule Effective 7/1/2013

Outpatient Hospital Services
– mental health services are covered when provided in an outpatient department of a general hospital. They are not covered at acute freestanding psych facilities.

Pre-Admission Screening and Resident Review (PASRR) –an administrative activity, which determines if applicants for nursing facility placement meet the criteria for needed specialized mental health services due to an indication of Mental Illness or Mental Retardation. The screening is performed by Community Mental Health Centers (CMHC) and Regional Centers around the State. If determined necessary, CMHCs may provide specialized mental health services to the resident in the nursing facility.

Fees for PASRR Administrative Services

PreAdmission Screening Resident Review Summary Level II

PreAdmission Screening Resident Review Summary Level II for MR form

Psychiatric Residential Treatment Facilities
–residential services for children under 21, with an average length of stay of 6 months. Prior authorization is required.

PRTF Providers

PRTF Reporting Requirements

PRTF On-Site Compliance Review Process

             Administrative Document Review

              Facility Tour

              Program Document Review

             Resident Interviews

             Resident Record Review

             Staff Interviews

Psychiatry Services by Physician or Nurse Practitioner
–limited to 12 visits per fiscal year, which do not affect the 12 physician office visits for medical issues. Children under the age of 21 may receive more visits, if medically necessary, with prior authorization. 

                                   Billing Guidelines for Mental Health/Psychiatry
     
Psychiatric Units at General Hospitals
–provide acute psychiatric services for both children and adults, with an average length of stay of 7-10 days. There is a limit of 30 days per fiscal year for adults. Children may have more days, if medically necessary. Prior authorization is required.

Fee Schedule by individual procedure code and service date through Envision

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