Statutes, codes, and regulations
Colorado Administrative Code
Department 2505 - Department of Health Care Policy and FinancingDivision 2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
Rule 10 CCR 2505-10-8.700 - MEDICAL ASSISTANCE - SECTION 8.700 Federally Qualified Health Centers, Women's Health Services
Section 10 CCR 2505-10-8.765 - SERVICES FOR CLIENTS IN RESIDENTIAL CHILD CARE FACILITIES AS DEFINED BELOW

10 Colo. Code Regs. § 2505-10-8.765

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Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.765 - SERVICES FOR CLIENTS IN RESIDENTIAL CHILD CARE FACILITIES AS DEFINED BELOW
8.765.1DEFINITIONS

Assessment means the process of continuously collecting and evaluating information to develop a client's profile on which to base a Plan of Care, service planning, and referral.

Clinical Staff means medical staff that are at a minimum licensed at the level of registered nurse, performing within the authority of the applicable practice acts.

Colorado Client Assessment Record (CCAR) means a clinical instrument designed to assess the behavior/mental health status of a medically eligible client. The CCAR is used to identify current diagnosis and clinical issues facing the client, to measure progress during treatment and to determine mental health medical necessity. This instrument is used for children in the custody of a county department of human/social services or Division of youth corrections and for those children receiving mental health services in an RCCF through the Child Mental Health Treatment Act.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the Colorado Medicaid program's benefit under Section 8.280 for children and adolescents that provides a comprehensive array of prevention, diagnostic, and treatment services for low-income infants, children and adolescents under age 21.

Emergency Safety Intervention means the use of Restraint and Seclusion as an immediate response to an Emergency Safety Situation.

Emergency Safety Situation means unanticipated behavior of the client that places the client or others at serious threat of violence or injury if no intervention occurs and that calls for Emergency Safety Intervention.

Emergency Services means emergency medical and crisis management services.

Independent Assessment means a process to assess the strengths and needs of the child using an age-appropriate, evidence-based, validated, functional assessment tool. The assessment determines whether treatment in a Qualified Residential Treatment Program (QRTP) provides the most effective and appropriate level of care for the child in the least restrictive environment, in accordance with Colorado Department of Human Services regulations.

Independent Team means a team certifying the need for Psychiatric Residential Treatment Facility (PRTF) services that is independent of the Referral Agency and includes a physician who has competence in the diagnosis and treatment of mental illness and knowledge of the client's condition.

Interdisciplinary Team means staff in a PRTF comprised of a physician, and a Licensed Mental Health Professional, registered nurse or occupational therapist responsible for the treatment of the client.

Licensed Mental Health Professional means a psychologist licensed pursuant to part 3 of article 43 of title 12, C.R.S., a psychiatrist licensed pursuant to part 1 of article 36 of title 12, C.R.S., a clinical social worker licensed pursuant to part 4 of article 43 of title 12, C.R.S., a marriage and family therapist licensed pursuant to part 5 of article 43 of title 12, C.R.S., a professional counselor licensed pursuant to part 6 of article 43 of title 12, C.R.S., or a social worker licensed pursuant to part 4 of article 43 or title 12, C.R.S., that is supervised by a licensed clinical social worker. Sections 12-43-301, et seq, 12-36-101, et seq, 12-43-401, et seq, 12-43-501, et seq and 12-43-601, et seq, C.R.S. (2005) are incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.

Medication Management Services means review of medication by a physician at intervals consistent with generally accepted medical practice and documentation of informed consent for treatment.

Multidisciplinary Team means staff in a Residential Child Care Facility (RCCF) providing mental health services comprised of at least one Licensed Mental Health Professional and other staff responsible for the treatment of the client and may include a staff member from the Referral Agency.

Plan of Care means a treatment plan designed for each client and family, developed by an Interdisciplinary or Multidisciplinary Team.

Prone Position means a client lying in a face down or front down position.

Psychiatric Residential Treatment Facility (PRTF) means a facility that is not a hospital and provides inpatient psychiatric services for individuals under age 21 under the direction of a physician, licensed pursuant to part 1 of article 36 of title 12, C.R.S.

Qualified Residential Treatment Programs (QRTP) means a facility that provides residential trauma-informed treatment that is designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances.

Referral Agency means the Division of Youth Corrections, County Departments of Human/Social Services who have legal custody of a client, Behavioral Healthcare Organization or Community Mental Health Center that refers the client to a PRTF or RCCF for the purpose of placement through the Child Mental Health Treatment Act.

Restraint includes Drug Used as a Restraint, Mechanical Restraint and Personal Restraint.

Drug Used as a Restraint means any drug that is administered to manage a client's behavior in a way that reduces the safety risk to the client or to others; has the temporary affect of restricting the client's freedom of movement and is not a standard treatment for the client's medical or psychiatric condition.

Mechanical Restraint means any device attached or adjacent to the client's body that the client cannot easily remove that restricts freedom of movement or normal access to the client's body.

Personal Restraint means personal application of physical force without the use of any device, for the purpose of restraining the free movement of the client's body. This does not include briefly holding a client without undue force in order to calm or comfort, or holding a client's hand to safely escort the client from one area to another. This does not include the act of getting the client under control and into the required position for Restraint.

Residential Child Care Facility (RCCF) means any facility that provides out-of-home, 24-hour care, protection and supervision for children in accordance with 12 C.C.R. 2509-8, Section 7.705.91.A.

Seclusion means the involuntary confinement of a client alone in a room or an area from which the client is physically prohibited from leaving.

8.765.2PRTF BENEFIT
8.765.2.A. PRTF benefit shall include services as identified in the Plan of Care as well as other services necessary for the care of the client in the facility. These services include, but are not limited to:
1. Individual therapy.
2. Group therapy.
3. Family, or conjoint, therapy conducted with the client present, unless client contact with family members is contraindicated.
4. Emergency services.
5. Medication Management Services.
6. Room and Board.
8.765.3PRTF NON-BENEFIT
8.765.3.A. The following are not a benefit in a PRTF:
1. The day of discharge.
2. Leave days.
3. Days when the client is in detention.
8.765.4PRTF CLIENT ELIGIBILITY
8.765.4.A. To receive benefits in a PRTF, the client shall:
1. Be between the ages of three and twenty-one.
2. Be certified to need PRTF level of care by an Independent Team. The Team shall certify that:
a. Ambulatory care resources available in the community do not meet the treatment needs of the client.
b. Proper treatment of the client's mental illness condition requires services on an inpatient basis under the direction of a physician.
c. The services can reasonably be expected to improve the client's mental health or prevent further regression so that the services shall no longer be needed.
3. Be certified to have a diagnosis of a psychiatric disorder classified as a Diagnostic Statistical Manual (DSM) IV Text Revision, Fourth Edition, diagnosis that is the primary reason for placement from one of the following diagnostic categories:

295 Schizophrenic disorders

296 Affective psychoses

297 Paranoid states

298 Other nonorganic psychoses

300 Neurotic disorders

301 Personality disorders

307 Eating Disorders, Tic Disorders and Sleep Disorders

308 Acute reaction to stress

309 Adjustment reaction

311 Depressive disorder, not elsewhere classified

312 Disturbance of conduct, not elsewhere classified

313 Disturbance of emotions specific to childhood and adolescence

314 Hyperkinetic syndrome of childhood

4. Be certified to have a DSM Axis 5 GAF score of 40 or less.
5. Be assessed using a current valid Colorado Client Assessment Record (CCAR) that supports medical necessity.
8.765.4.B. The client shall be not be eligible to receive services when:
1. The client is no longer able to benefit from the service or is no longer progressing towards goals.
2. The client is absent without leave in excess of 24 consecutive hours or has been removed from the facility and placed in non-PRTF services.
3. The Interdisciplinary Team determines that the client has attained treatment goals.
4. Admission of minors not in the custody of a County Department of Human/Social Services or DHS as a result of commitment to the Division of Youth Corrections shall be subject to the requirements set forth at Section 27-10-103, C.R.S (2005), which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.
8.765.5PRTF PROVIDER ELIGIBILITY
8.765.5.A. All PRTF Providers shall have an Interdisciplinary Team.
1. The Interdisciplinary Team shall include either a board-certified psychiatrist, or a clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy, and one of the following:
a. A licensed clinical social worker, licensed marriage and family therapist or licensed professional counselor.
b. A registered nurse with specialized training or one year's experience in treating mentally ill individuals.
c. A certified occupational therapist with specialized training or one year's experience in treating mentally ill individuals; or
d. A licensed psychologist.
2. The Interdisciplinary team shall:
a. Assess the client's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities.
b. Assess the potential resources of the client and client's family.
c. Develop and implement a comprehensive, individualized written Plan of Care.
d. Set treatment objectives.
e. Prescribe therapeutic modalities to achieve the objectives of the Plan of Care.
8.765.5.B. All PRTF providers shall implement a Plan of Care.
8.765.5.C. An initial Plan of Care shall be developed within 72 hours of the client's admission and shall address the immediate and emergency needs of the client.
8.765.5.D. A comprehensive Plan of Care shall:
1. Be completed within 14 days of admission.
2. Be signed and dated by the client, the Referral Agency and the Licensed Mental Health Professional.
3. Address clinical and other needs including the client's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
4. Include specific goals and measurable objectives, expected dates of achievement and specific discharge criteria to be met for termination of treatment. Criteria for discharge shall include provisions for follow-up services.
5. Specify the type, frequency and duration of all PRTF services necessary to meet the needs of the client and to treat the client's current diagnosis.
6. Identify the provision of or the referral for services other than PRTF Services.
7. Be readily identifiable and be maintained in the client's record.
8. Document any court-ordered treatment including identifying the agency responsible for providing the court-ordered treatment.
9. Include revisions to the Plan of Care at least monthly, or sooner if appropriate.
8.765.5.E. The PRTF shall designate a Licensed Mental Health Professional to act as a case manager for each client to oversee the formulation, implementation, review and revision to the Plan of Care.
8.765.5.F. The Licensed Mental Health Professional shall sign and date the Plan of Care.
8.765.5.G. The PRTF shall ensure the client and/or legal guardian participate in the formulation, review and revision of the Plan of Care. If the client or legal guardian is unable to participate or when his or her participation is clinically contraindicated, the PRTF shall document the reasons in the client's record. Any decision to not involve the family or guardian shall be approved by the Referral Agency. In addition, other persons selected by the client, the family or guardian, the Referral Agency or the Licensed Mental Health Professional may be included in the formulation, review and revision of the Plan of Care.
8.765.5.H Except in cases of emergency, all PRTF services in the Plan of Care shall be provided.
8.765.5.I. The PRTF shall ensure that physician prescribed information is used for the component of the Plan of Care requiring Medication Management Services.
8.765.5.J. The PRTF shall ensure all clients and/or guardians are aware of the complaint and grievance procedures.
8.765.5.K. The PRTF shall ensure all clients and/or guardians are aware of the PRTFs policies regarding Restraint and Seclusion as required in 42 C.F.R. 483.350-376, which is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203-1714. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.
8.765.5.L. The PRTF shall facilitate access to necessary medical care and shall be responsible for coordinating mental health treatment with medical treatment.
8.765.5.M. Client Transfers:
1. A client shall be transferred only to the care of another PRTF or placement facility when adequate arrangements for care have been made by the Referral Agency.
2. The client and the legal guardian shall be given a minimum of 24 hours notice before the client is transferred unless this notice is waived by the Referral Agency or legal guardian in writing or if an emergency condition exists.
3. Transfers shall be documented in the clinical record.
8.765.5.N. PRTF Licensure and Certification Requirements.
1. The PRTF shall:
a. Be certified by the Department of Human Services (DHS), to provide mental health services as a PRTF.
b. Be licensed by DHS, Division of Child Care Licensing, as a Residential Child Care Facility and a PRTF.
c. Be certified as a qualified residential provider by the Department of Public Health and Environment.
d. Be accredited by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children.
e. Provide an attestation to the Department that the PRTF is in compliance with the condition of participation for Restraint and Seclusion as described in Section 8.765.6.F and in federal law.
2. A PRTF located in another state shall meet the requirements as set forth in Section 8.765.5.N.1.d . and e. and shall meet all other license and certification requirements for a PRTF in the state in which it is located.
3. A PRTF that has more than one physical address shall have a separate Medicaid provider number for each facility.
8.765.6PRTF PROVIDER RESPONSIBILITIES
8.765.6.A. A PRTF shall complete a CCAR and maintain an organized, legible, chronological, current treatment record for each client. Treatment records shall include:
1. Admission information such as the client's personal information and demographic data, source of referral, most current Diagnostic Statistical Manual diagnosis and substance abuse history.
2. Documentation of the client's legal status, including but not limited to guardianship, conservatorship, court orders, custody, certifications, advisement and consent.
3. Copies of all CCARs.
4. All Plans of Care and revisions.
5. Documentation of client's attendance at, participation in and outcomes of PRTF Services.
6. Documentation that the client and/or the legal guardian was provided with a copy of the Plan of Care.
7. Correspondence to and from agencies and individuals involved in the client's treatment.
8. An explanation whenever any member of the Interdisciplinary Team, client, parent or guardian, when appropriate, does not sign a Plan of Care.
9. The name of the Licensed Mental Health Professional responsible for the formulation, implementation, review and revision of the client's Plan of Care.
10. A discharge report, within 30 consecutive days of the discharge from the PRTF, summarizing treatment received and outcomes.
11. For transfers between facilities, documentation of appropriate clinical information and coordination of services between the two facilities.
12. Documentation of any unplanned discharges without advance notice and any discharges against the Licensed Mental Health Professional's advice.
13. Information regarding any serious injury sustained while in the PRTF to the client or by the client and details describing the circumstances by which the injury occurred.
14. Information regarding a client's death and details of the circumstances by which the death occurred.
15. Dates, times and circumstances of unauthorized leave.
16. Documentation of detention dates.
17. Treatment entries that are signed and dated by the person providing treatment, including title or position of the person providing treatment.
8.765.6.B. All members of the Clinical Staff shall be trained annually in the development and review of Plans of Care and the details of this training shall be documented.
8.765.6.C. Records shall be kept in a secure location at the PRTF.
8.765.6.D. Data, including claims data, shall be retained for six years unless there is a written statutory requirement or regulation available from a county, state or federal agency requiring a longer retention period.
8.765.6.E. Clinical records shall be retained for six years after the client's 21st birthday.
8.765.6.F. The PRTF shall comply with the following requirements for the use of Restraint and Seclusion:
1. Personal, Mechanical and Drugs Used as Restraint shall be ordered only by a physician, physician's assistant or nurse practitioner.
2. An order for Restraint or Seclusion shall not be written as a standing order or on an as-needed basis.
3. Restraint and Seclusion shall not result in harm or injury to the client and shall be used only to ensure the safety of the client or others during an Emergency Safety Situation and only until the Emergency Safety Situation has ceased.
4. Restraint and Seclusion shall not be used simultaneously.
5. A Personal Restraint when a client is in a Prone Position is prohibited.
6. If the order for Restraint or Seclusion is verbal, it shall be received by a registered nurse, licensed practical nurse or physician's assistant.
7. The Restraint or Seclusion shall be carried out by Clinical Staff who are trained in the use of emergency safety intervention.
8. Only a physician, registered nurse, licensed practical nurse or physician's assistant shall administer a Drug Used as a Restraint.
9. Clinical Staff trained in the use of emergency safety interventions that are physically present during the Restraint or Seclusion shall monitor the client during the Restraint or Seclusion period.
10. Each order for Restraint or Seclusion shall never:
a. Exceed the duration of the emergency safety situation; and
b. Exceed four hours in length for youth ages 18 to 21; two hours in length for clients ages nine to 17; or one hour in length for clients under age of nine.
11. Within one hour of the initiation of the Emergency Safety Intervention a physician, registered nurse or physician's assistant shall conduct a face-to-face assessment of the physical and psychological well being of the client. A psychologist may conduct the face-to-face assessment if done in conjunction with a physician, registered nurse or physician's assistant.
12. The PRTF shall report each serious occurrence to both the Department and the federally-designated Protection and Advocacy agency no later than close of business the next business day. Serious occurrences to be reported include a client's death, a serious injury to a client, or a client's suicide attempt.
13. The PRTF shall notify the parent(s) or legal guardian(s) of a client who has been restrained or secluded as soon as possible, but not to exceed 24 hours, after the initiation of each emergency safety intervention and shall document the date and time of this notification in the client's record.
14. Within 24 hours of the use of Restraint or Seclusion, staff involved in an Emergency Safety Intervention and the client shall have a face-to-face discussion. This discussion shall include all staff involved in the intervention except when the presence of a particular staff person may jeopardize the well-being of the client. Other staff and the client's parent or guardian may participate in the discussion, if appropriate.
15. Within 24 hours after the use of Restraint or Seclusion, all staff involved in the Emergency Safety Intervention, and appropriate supervisory and administrative staff, shall conduct a debriefing session that includes, at a minimum, a review and discussion of:
a. The situation that required the intervention, including a discussion of the precipitating factors that led up to the intervention.
b. Alternative techniques that may have prevented the use of the Restraint or Seclusion.
c. New procedures implemented to mitigate any recurrence of the use of Restraint or Seclusion.
d. The outcome of the intervention, including any injuries that may have resulted from the use of Restraint or Seclusion.
8.765.7REIMBURSEMENT FOR PRTFs
8.765.7.A. A PRTF shall be reimbursed a per diem rate as determined by DHS and approved by the Department.
8.765.7.B. The Department shall recover the per diem reimbursement when:
1. Each service is not documented in the treatment record at the frequency specified in the Plan of Care.
2. There is no Plan of Care in the record, for the period of time claims were paid.
3. Records are requested but not provided with 21 calendar days.
8.765.C. A PRTF may appeal the Department's recovery actions within 30 calendar days from the date of notice. The appeal shall be submitted in accordance with 10 C.C.R. 2505-10, Section 8.050.
8.765.8MENTAL HEALTH BENEFITS FOR CLIENTS IN AN RCCF
8.765.98.A. Family therapy shall not exceed maximum of one service unit per day.
1. Family therapy without the client present may be provided at a maximum of one service unit per week if treatment is documented in the Plan of Care that client contact with family members is contraindicated. Family Therapy without the client present shall be for the specific benefit of the client.
8.765.8.B. Individual therapy shall not exceed two service units per day.
8.765.8.C. Group therapy shall not exceed eight service units per day.
8.765.8.D. A Licensed Mental Health Professional may authorize family, individual and group therapy in excess of maximum service units per day if the following is documented in the Plan of Care:
1. The reason for the additional therapy.
2. How many additional units are necessary.
3. How long the additional therapy is necessary.
8.765.8.E. The Licensed Mental Health Professional shall re-authorize therapy in excess of the maximum service units per day in the Plan of Care at least every 30 days.
8.765.8.F. Beginning July 1, 2022, only services rendered under Early and Periodic Screening, Diagnosis and Treatment in accordance with Section 8.280 are a covered RCCF benefit.
8.765.9NON-COVERED BENEFITS FOR CLIENTS IN AN RCCF
8.765.9.A. The following benefits are not covered for clients in an RCCF:
1. Court-ordered treatment that is not otherwise medically indicated;
2. Room and board services;
3. Educational, vocation and job training services;
4. Recreational or social activities;
5. Habilitative care for children who are developmentally disabled or mentally retarded; and
6. Services provided by public institutions or institutions for mental diseases.
8.765.10CLIENT ELIGIBILITY FOR MENTAL HEALTH SERVICES IN AN TRCCF
8.765.10.A. To be eligible for mental health services delivered in an RCCF the client shall:
1. Be between the ages of three and 21 years of age.
2. Have a diagnosis of a psychiatric disorder classified by a Diagnostic and Statistical Manual of Mental Disorders (DSM).
3. Have a current, and valid CCAR assessment completed by a Licensed Mental Health Professional that supports medical necessity for mental health services, and demonstrates which services the client would benefit from.
8.765.11ELIGIBILITY FOR PROVIDERS DELIVERING SERVICES IN AN RCCF
8.765.11.A Individual, group and family therapy provided in an RCCF shall be provided by a Licensed Mental Health Professional or a provisionally-licensed Mental Health Professional supervised by a Licensed Mental Health Professional, employed by or contracted with an RCCF that is licensed by the Colorado Department of Human Services.
8.765.11.B. Licensed Mental Health Professionals providing mental health services to clients in an TRCCF are exempt from the direct physician supervision requirement in 10 C.C.R. 2505-10, Section 8.200.2.A through E.
8.765.11.C. Licensed Mental Health Professionals providing mental health services to clients in the RCCF enroll as Medicaid rendering providers.
8.765.12RCCF RESPONSIBLITIES
8.765.12.A. The RCCF shall include the following in the client's record:
1. Results from the Multidisciplinary Team's Assessment;
2. Client's Medicaid Eligibility Determination Form; and
3. Client's diagnoses, characteristics and presenting problem.
8.765.12.B. The RCCF shall transmit the items listed in 8.765.12.A. to the Referral Agency.
8.765.12.C. The RCCF shall designate a Licensed Mental Health Professional to act as a case manager for mental health services for each client.
8.765.12.D. The Licensed Mental Health Professional shall maintain an organized, legible, chronological, current record on each client.
8.765.12.E. The client's Plan of Treatment for mental health services shall be integrated into the agency's comprehensive Plan of Care reviewed by the Multidisciplinary Team. The Plan of Care shall:
1. Be signed and dated by the client, the Referral Agency and the Licensed Mental Health Professional and the parent/guardian.
2. Include an initial plan developed prior to the onset of mental health services that needs of the client.
3. Address mental health and other needs including the client's presenting problems, physical health, emotional status, behavior, support system in the community, available resources and discharge plan.
4. Include specific goals and measurable objectives, expected dates of achievement and specific discharge criteria to be met for termination of treatment. Criteria for discharge shall include provisions for follow-up services.
5. Specify all mental health services necessary to meet the needs of the client and to treat the client's current diagnosis while the client is in the RCCF.
6. Identify the provision of or the referral for services other than mental health services.
7. Be readily identifiable and be maintained in the client's record.
8. Document any court-ordered mental health services including identifying the agency responsible for providing the court-ordered treatment.
9. Be reviewed by the Multidisciplinary Team monthly and revised as needed.
8.765.12.F. Except in cases of emergency, all mental health services indicated in the Plan of Care shall be provided.
8.765.13REIMBURSEMENT FOR MENTAL HEALTH SERVICES IN A TRCCF
8.765.13.A. Reimbursement for Mental Health Services in a RCCF shall be the lower of billed charges or the maximum unit rate of reimbursement. Beginning July 1, 2022, RCCF services will be not reimbursable unless provided under Early and Periodic Screening, Diagnosis and Treatment in accordance with Section 8.280.
8.765.13.B. The RCCF shall enroll as a Medicaid provider for the purposes of acting as a billing entity for Licensed Mental Health Professionals providing mental health services in the RCCF.
8.765.14QUALIFIED RESIDENTIAL TREATMENT PROGRAM (QRTP)
8.765.14.ACLIENT ELIGIBILITY
1. Children up to age eighteen (18) years old and for those persons up to twenty-one (21) years old who consent to the placement or are placed by court order, for whom an Independent Assessment determines that the child's needs cannot be met in a less restrictive, family - based setting because of their serious emotional or behavioral disorders or disturbances.
2. Managed Care Entities must use the Independent Assessment to inform medical necessity determinations.
3. For children in the custody of a county department of human/social services or Division of Youth Services and for those children receiving mental health services in a Qualified Residential Treatment Program (QRTP) through the Child and Youth Mental Health Treatment Act, the Independent Assessment will determine mental health medical necessity.
8.765.14.BQRTP AND PROVIDER ELIGIBILITY
1. Beginning October 1, 2021, to be eligible for Colorado Medicaid reimbursement, a QRTP must:
a. Be enrolled with Colorado Medicaid;
b. Be licensed by the Colorado Department of Human Services (CDHS), Provider Services Unit (PSU), as a Child Care Facility with QRTP indicated as the Service Type in accordance with CDHS regulations;
c. Be accredited by:
i. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
ii. The Commission on Accreditation of Rehabilitation Facilities (CARF),
iii. The Council on Accreditation of Services for Families and Children, or
iv. Any other independent, not-for-profit accrediting organization approved by the Secretary of Health and Human Services.
d. Submit an attestation form to the Department with the facility's Colorado Medicaid enrollment application with Colorado Medicaid that attests:
i. The facility has no more than sixteen (16) beds, including all beds at a single address or on adjoining properties regardless of program or facility type;
ii. The facility does not share a campus with a Psychiatric Residential Treatment Facility (PRTF);
iii. For facilities more than one (1) mile but less than ten (10) miles apart by road from another overnight facility controlled by the same ownership or governing body, the other overnight facility meets the following criteria:
1. The facility maintains its own license;
2. The facility has dedicated staff that ensures a stable treatment environment;
3. Residents do not move between the facility and another during the episode of care
iv. For facilities less than one (1) mile apart, but not on the same campus or adjoining properties, the QRTP is in a home-like structure (cottage, house, apartment) located farther than 750 feet from another overnight facility within a community setting that includes publicly used infrastructure (roads, parks, shared spaces, etc.).
2. Provider Qualifications.
a. The rendering provider for the following services must be an enrolled Licensed Mental Health Professional in a QRTP:
i. Individual therapy,
ii. Group therapy, and
iii. Family therapy.
8.765.14.CCOVERED SERVICES
1. Medically necessary services pursuant to Section 8.076.1.8 that are not excluded in Section 8.765.14.D and are:
a. Included in the member's stabilization plan created by the QRTP in accordance Colorado Department of Human Services (CDHS) regulations.
b. Included in the member's individual child and family plan created by the QRTP in accordance with CDHS regulations.
c. Included in the member's discharge and aftercare plan created by the QRTP in accordance with CDHS regulations.
2. All EPSDT services not specified in Sections 8.765.14.C.1 -3 are covered under Section 8.280.
8.765.14.DNON-COVERED SERVICES
1. The following services are not covered for members in a QRTP:
a. Room and board;
b. Educational, vocational, and job training services;
c. Recreational or social activities; and
d. Services provided to inmates of public institutions or residents of Institutions of Mental Disease (IMD).
8.765.14.EPRIOR AUTHORIZATION REQUIREMENTS
1. Prior authorization may be required for this benefit.
8.765.14.FREIMBURSEMENT.
1. QRTPs are reimbursed a per diem rate, as determined by the Department, if the following conditions are fulfilled:
a. Rendered services are documented in the treatment record at the frequencies specified in the member's care plan(s);
b. A care plan(s) is on record for the time period reported in the reimbursement claim; and
c. The care meets professionally recognized standards for care in a QRTP.
2. QRTPs must enroll as a Colorado Medicaid provider to act as a billing entity for Licensed Mental Health Professionals rendering mental health services in the QRTP.

10 CCR 2505-10-8.765