016.06.05 Ark. Code R. 034
In order to ensure quality and continuity of care, all mental health providers approved to receive Medicaid reimbursement for services to Medicaid recipients must meet specific qualifications for their services and staff.
To enroll as an RSPMI Medicaid provider, the following must occur:
Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Contract.
DMS shall exclude providers for the reasons stated in 42 U.S.C. § 1320c-7(a) and implementing regulations and may exclude providers for the reasons stated in 42 U.S.C. § 1320c-7(b) and implementing regulations.
The following factors shall be considered by DHS in determining whether sanction(s) should be imposed:
A range of mental health rehabilitative or palliative services is provided by a duly certified RSPMI provider to Medicaid-eligible recipients suffering from mental illness, as described in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV and subsequent revisions).
Rehabilitative Services for Persons with Mental Illness may be covered only when:
If the beneficiary receives care under the treatment plan, the initial treatment plan/plan of care must be approved by the physician within 14 calendar days of the initial receipt of care.
The physician's signature is not valid without the date signed.
Prior to providing treatment services, an intake evaluation must be performed for each recipient being considered for entry into a RSPMI Program. The evaluation is a written assessment that evaluates the recipient's mental condition and, based on the recipient's diagnosis, determines whether treatment in the RSPMI Program would be appropriate. The assessment must be made a part of the recipient's records.
The intake evaluation must be conducted by a mental health professional qualified by licensure and experienced in the diagnosis and treatment of mental illness.
For each recipient served through the RSPMI Program, the treatment team must certify that the program is appropriate to meet the recipient's needs. This certification must be documented in the recipient record within 14 calendar days of the person's entering continued care (first billable service), through treatment team signatures on the treatment plan/plan of care. The treatment team must include, at a minimum, a physician and an individual qualified, by licensure and experience, in diagnosis and treatment of mental illness. (Both criteria may be satisfied by the same individual, if appropriately qualified.)
Services designated by the following HCPCS procedure codes do not require PCP referral:
As stated above, a PCP referral is required for Medicaid beneficiaries under age 21. It is recommended that the provider obtain the PCP referral prior to providing service to Medicaid-eligible children. However, a PCP is given the option of providing a referral after a service is provided. If a PCP chooses to make a referral after a service has been provided, the referral must be received by the RSPMI provider no later 45 calendar days after the date of service. The PCP has no obligation to give a retroactive referral.
The RSPMI provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral is received.
A PCP is given the option of providing a referral after a service is provided. However, the PCP has no obligation to give a retroactive referral. The RSPMI provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral has been received.
To verify the authorization date, a provider may call EDS or the local DHS office.
View or print EDS PAC contact information. View or print the DHS office contact information.
The RSPMI treatment plan/plan of care must be periodically reviewed by the treatment team in order to determine the recipient's progress toward the rehabilitative treatment and care objectives, the appropriateness of the rehabilitative services provided and the need for the enrolled recipient's continued participation in the RSPMI Program. The reviews must be performed on a regular basis (at least every 90 calendar days), documented in detail in the enrolled recipient's record, kept on file and made available as requested for state and federal purposes. If provided more frequently, there must be documentation of significant acuity or change in clinical status requiring an update in the recipient's treatment plan/plan of care. The clock for the 90-day review begins to run on the earliest date set forth on the form that contains the treatment plan.
Restricted RSPMI services may be provided only to individuals certified as having a serious mental illness (for individuals age 18 or older) or serious emotional disturbance (children and adolescents under the age of 18). The definition and certification process for serious mental illness and serious emotional disturbance is determined by the Division of Behavioral Health Services (DBHS). For individuals who receive any restricted services during the first 14 calendar days after entering care, the physician certification form must be completed, signed and dated by the physician within 14 calendar days of the individual's entering care (first billable service).
A form to be completed and filed in the patient record to establish the need for restricted services for Medicaid recipients age 21 and over may be found on the DBHS web site. The form must be completed and filed in the patient record.
A form to be completed and filed in the patient record to establish the need for restricted services for Medicaid recipients under age 21 may be found on the DBHS web site. The form must be completed and filed in the patient record.
Forms for the determination of eligibility to receive restricted services are available for downloading from the DBHS Web site (http://www.arkansas.gov/dhs/dmhs/).
Services not covered under the RSPMI Program include, but are not limited to:
(reimbursement for other RSPMI services is not allowed for the period of time the Medicaid recipient is in transport);
The RSPMI provider must develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity or session for which Medicaid reimbursement is sought. This documentation, at a minimum, must consist of:
Documentation must be legible and concise. The name and title of the person providing the service must reflect the appropriate professional level in accordance with the staffing requirements found in section 213.000.
For Therapeutic Day/Acute Day and Rehabilitative Day Services, daily progress notes must be entered the day the service is delivered. Daily notes may be brief; however, they must meet requirement of item F above. Providers may enter weekly progress notes that summarize the recipient's progress in relationship to the plan of care.
All documentation must be available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business. No more than thirty (30) days will be allowed after the date on the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the 30-day period.
016.06.05 Ark. Code R. 034