D.C. Mun. Regs. r. 22-A3010

Current through Register Vol. 71, No. 25, June 21, 2024

Rule 22-A3010 - REIMBURSEMENT

3010.1

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.

3010.2

A participating FSMHC shall agree to bill any and all other known third-party payers prior to billing Medicaid or the District.

3010.3

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.

3010.4

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.

3010.5

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.

3010.6

Recreational therapy shall not be reimbursed as an FSMHC service.

3010.7

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.

3010.8

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:

(a) Diagnostic Evaluation - behavior assessment procedures used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the treatment planning process;

(b) Psychiatric Diagnostic Evaluation - integrated biophysical assessments, including history, mental status, and recommendations;

(c) Comprehensive Psychological Testing - up to five (5) hours of psychometric and projective tests with a written report done under the direction of a psychologist;

(d) Therapy:

(1) Individual Psychotherapy - verbal, drug augmented, or other therapy methods provided by a behavioral health practitioner in a face-to-face involvement with one (1) consumer to the exclusion of other consumers and duties. Session length is pursuant to the Current Procedural Terminology (CPT) Manual (most current edition);

(2) Family therapy - therapy with or without the consumer and one (1) or more family members present. Verbal or other therapy methods by a behavioral health practitioner in a personal involvement with the consumer and family to the exclusion of other consumers and duties. Session length is pursuant to the CPT Manual (most current edition). The clinic may bill Medicaid only for the Medicaid consumer; and

(3) Group therapy - verbal or other therapy methods provided by a behavioral health practitioner in face-to-face involvement with at least three (3) and no more than twelve (12) consumers. Session length is pursuant to the Current Procedural Terminology (CPT) Manual (most current edition);

(e) Prescription visits - a visit with a physician for review and evaluation of the medication history of the consumer and the writing or renewal of prescriptions as necessary. A minimum of ten (10) minutes shall be allotted to the visit; and

(f) Family conferences - meeting with the family or other significant persons (school, court, or other agency officials) to interpret or explain: medical, psychiatric, or psychological examinations and procedures; other accumulated data; and advice on how to assist the patient. A minimum of fifty (50) minutes shall be allotted to personal involvement with the family or other significant persons. The FSMHC may bill Medicaid only for the Medicaid patient.

3010.9

Behavioral health practitioners for FSMHC are described below:

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) * Advance 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	* LGSW
* Psychologist * LICSW * APRN * LPC * LMFT	* LGPC * LISW * Psychology Associate * Students, interns, or residents for any of the allowed licenses for therapy
Prescription Visits	* Psychiatrist * APRN	* 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

3010.10

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. r. 22-A3010

Final Rulemaking published at 67 DCR 11929 (10/16/2020); amended by Final Rulemaking published at 69 DCR 13495 (11/4/2022)