TX.CP.MP.544 Mental Health Rehabilitation and Targeted Case Management
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP
| It is the policy of Superior that Medicaid MHR/TCM and CHIP Skills Training services are medically necessary when the following are met:
- Required Documentation: MHR/TCM provider must submit the following information prior to providing services to a member.
- Prior Authorization Request Form
- Documentation of Licensed Practitioner of the Healing Arts (LPHA) clinical diagnosis that must fulfill all of the following:
- Rendered by an LPHA, acting within the scope of their license, who has interviewed the member; and
- Based on diagnostic criteria from the latest edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders; and
- Documented in writing, including the date, signature, and credentials of the person making the diagnosis; and must be updated at least annually; and
- Supported by and included in the uniform assessment.
- Clinical Management for Behavioral Health Services (CMBHS) Report, including the complete Uniform Assessment (Child and Adolescent Needs and Strengths (CANS) and Adult Needs and Strengths Assessment (ANSA)). NOTE: CANS 3.0 will not meet this requirement
- The assessment must be completed by a Qualified Mental Health Professional- Community Services (QMHP-CS) with appropriate supervision and training and have all the following documented:
- the members’ identifying information;
- completion of the uniform assessment(s) and assessment guideline calculations;
- The member's present status and relevant history, including education,
- employment, housing, legal, military, developmental, and current available social and support systems;
- The member's co-occurring substance use, intellectual or developmental
- disability, or physical health condition, if any;
- The members’ relevant past and current medical and psychiatric information, which may include trauma history;
- Information from the member and LAR, if applicable, regarding the member’s strengths, needs, natural supports, community participation, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;
- The need or desire of the member for family member involvement or other identified natural supports in treatment and mental health community services, if the member is an adult without a LAR;
- The identification of the LAR's or family members' need for education and support services related to the member's mental illness or emotional disturbance and the plan to facilitate the LAR's or family members' receipt of the needed education and support services;
- Recommendations and conclusions regarding treatment needs,
- The mode of delivery; and
- Date, signature, and credentials of the staff member completing the assessment.
- Recovery Plan with all the required elements indicated in the following section.
- Recovery/Treatment Planning, Recovery/Treatment Plan Review, and Discharge Summary
- An MHR/TCM provider must develop a written recovery/treatment plan:
- Before the provision of mental health targeted case management or mental health rehabilitative services; and
- Within 10 business days after the date the member is eligible and has been authorized for routine care services. NOTE: The recovery plan must be completed prior to the start of services. The dates on the recovery plan should align with the prior authorization request.
- Credentials for completing recovery/treatment plan. A staff member credentialed as a QMHP-CS, at a minimum, is responsible for completing and signing the plan.
- Content of recovery plan
- The plan must reflect input from the member and each of the disciplines of treatment to be provided to the member based on the assessment. The plan must include all the following:
- a description of the members’ presenting problem(s);
- a description of the members’ strengths;
- a description of the members’ needs arising from the mental illness or serious emotional disturbance;
- a description of the members’ co-occurring substance use disorder, intellectual or developmental disability, or physical health condition(s), if any;
- a description of the recovery goals and objectives based on the assessment, and expected outcomes of the treatment in accordance with paragraph (2) of this subsection;
- the expected date by which the recovery/treatment goals will be achieved; and
- a list of the type(s) of intervention(s) within each form of treatment that will be provided to the member (e.g., psychosocial rehabilitation, medication services, supported employment), and for each type of service listed:
- a description of the strategies to be implemented by staff members in providing the service and achieving goals;
- the frequency, number of units (e.g.), and duration of each service to be provided (e.g., .5 hours of counseling per month, 1.5 hours of skills training per month for 3 months); and
- the credentials of the staff member responsible for providing the service.
- The goals and objectives with expected outcomes must:
- specifically address the member's unique needs, preferences, experiences, and cultural background;
- specifically address the member's co-occurring substance use or physical health disorder, if any;
- be expressed in terms of overt, observable actions of the member;
- be objective and measurable using quantifiable criteria; and
- reflect the member's self-direction, autonomy, and desired outcomes.
- Review of recovery/treatment plan (applicable only to requests for continuation of services) An MHR/TCM provider must complete the assessment within the timeframe below:
- Review a member's continued eligibility for services as specified in §354.2703;
- A QMHP-CS conducts an assessment to determine the individual's continued eligibility for services.
- An adult is automatically eligible for continued services, regardless of whether his or her level of functioning has improved and regardless of requirements described in this section, if the individual has a diagnosis of:
- schizophrenia (including schizoaffective disorder);
- bipolar disorder; or
- major depressive disorder with a level of functioning that qualified the individual initially, or
- an adult is reassessed for continued eligibility for mental health rehabilitation at least every 180 days or more frequently if clinically indicated.
- A child or youth is reassessed for continued eligibility for mental health rehabilitation:
- at least every 90 days; or more frequently if clinically indicated.
- If more than 180 days have passed for adults or 90 days for children between assessments, there may be a gap in authorization.
- Review a member's plan prior to requesting authorization for the continuation of services, including all the following:
- determining if the plan adequately addresses the needs of the member; documenting progress on all goals and objectives; and
- documenting any recommendation for continuing services, any change from current services, and any discontinuation of services.
- Deviations
- Deviations will be reviewed utilizing the Texas Resilience and Recovery Utilization Management Guidelines.
- Exclusions
- The covered Medicaid services listed below must not be provided concurrently and will not be reimbursed separately:
- Routine (T1017-TF) and Intensive Case Management Services (T1017-TG) are not to be authorized or provided concurrently.
- If psychosocial rehabilitative services (H2017) are in the treatment plan, the treatment plan cannot simultaneously include skills training and development (H2014) or targeted case management (T1017) services.
- Psychosocial rehabilitative services (H2017) may not be provided to a person who is currently admitted to a crisis stabilization unit.
- Services are not reimbursable in the inpatient setting.
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