In order to be reimbursed, FSMHC services shall be medically necessary, reasonable in duration, and in full compliance with this chapter. A participating FSMHC shall agree to accept as payment in full the amount determined by DHCF or the Department, as appropriate, as the fee for the authorized services provided to Medicaid consumers and other eligible consumers for whom the District of Columbia is reimbursing the provider for services. No additional charge may be made to the consumer, any member of the family, or to any other source.
A participating FSMHC shall agree to bill any and all other known third-party payers prior to billing Medicaid or the District.
The payment and satisfaction of any FSMHC claim will be from federal and District funds. Any false claims, statements, documents, or concealment of material facts by the FSMHC shall be referred to the DHCF Office of Program Integrity and considered grounds for denial of claims, recoupment of false claims previously paid, and decertification. These remedies are in addition to any other remedies that the law may provide for false claims.
DHCF and the Department shall establish rates and reimburse for only those services outlined in §§ 3010.8 and provided under the direction of a psychiatrist. Reimbursement for Medicaid-funded and locally-funded FSMHC services shall be at the rate contained in the District of Columbia Medicaid fee schedule available online at www.dc-medicaid.com. All future updates to the service codes and rates will be included in the District of Columbia Medicaid fee schedule pursuant to the procedures established in 29 DCMR §§ 988. Health Home services provided by a FSMHC shall be provided in accordance with the requirements set forth in 29 DCMR §§ 6900 et seq. and 22-A DCMR §§ 2500 et seq.
Treatment-related services, such as information and referral services, charting, internal case conferences, transportation, person and agency conferences, and similar charges shall not be reimbursable under these rules. FSMHCs certified as a Health Home shall be reimbursed for the provision of Health Home services in accordance with the requirements set forth in 29 DCMR §§ 6900 et seq. and 22-A DCMR §§ 2500 et seq.
Recreational therapy shall not be reimbursed as an FSMHC service.
Excluding Health Home services provided in accordance with requirements set forth in 29 DCMR §§ 6900 et seq. and 22-A DCMR §§ 2500 et seq., a participating FSMHC may be reimbursed for no more than one individual therapy session, one group therapy session, and one psychiatrist visit per person on the same day. Any other service combinations require prior approval from the Department before service delivery.
The following services shall be reimbursable if the independently licensed behavioral health practitioner certifies that the services are medically necessary, a current plan of care outlines the required services, and the services are provided by a behavioral health practitioner acting within applicable Federal and District laws and regulations:
Behavioral health practitioners for FSMHC are described below:
SERVICE | INDEPENDENTLY LICENSED BEHAVIORAL HEALTH PRACTITIONER | LICENSED BEHAVIORAL HEALTH PRACTITIONER AND OTHER BEHAVIORAL HEALTH PRACTITIONER WITH SUPERVISION |
Diagnostic Evaluation | * Psychiatrist * Psychologist * Licensed Independent Clinical Social Worker (LICSW) * Advanced Practice Registered Nurse (APRN) * Licensed Professional Counselor (LPC) * Licensed Marriage and Family Therapist (LMFT) | * Licensed Graduate Social Worker (LGSW) * Licensed Graduate Professional Counselor (LGPC) * Licensed Independent Social Worker (LISW) * Registered Nurse (RN) * Physician Assistant * Psychology Associate * Students, interns, or residents for any of the allowed licenses for examination and assessment |
Psychiatric Diagnostic Evaluation | * Psychiatrist * APRN | * Physician Assistant |
Comprehensive Psychological Testing | * Psychologist | * Psychology Associate * Psychology student/intern |
Therapy | * Psychiatrist * Psychologist * LICSW * APRN * LPC * LMFT | * LGSW * LGPC * LISW * Psychology Associate * Students, interns, or residents for any of the allowed licenses for therapy |
Prescription Visits | * Psychiatrist * Physician * APRN | * Licensed Practical Nurse * RN * Physician Assistant |
Family Conferences | * Psychiatrist * Psychologist * LICSW * APRN * LPC * LMFT | * LGSW * LGPC * LISW * RN * Psychology Associate * Students, interns, or residents for any of the allowed licenses for therapy |
All claims seeking Medicaid or local only reimbursement under this Chapter shall include the active NPI numbers for the certified provider and the rendering provider. The rendering provider is the staff member who provided the service.
D.C. Mun. Regs. tit. 22, r. 22-A3010