471 Neb. Admin. Code, ch. 20, § 001
Effective July 1, 1995, the requirements of this chapter apply to all psychiatric services for individuals age 21 and older provided under the Nebraska Medical Assistance Program (NMAP).
Mental health and substance abuse services (MH/SA) are provided as a managed care benefit for all Nebraska Medicaid Managed Care (NMMCP) clients. The benefit includes the Client Assistance Program (CAP). Clients may access five services annually with any CAP-enrolled provider without prior authorization. All other MH/SA services must be prior authorized.
The Department's philosophy is that all care provided to clients must be provided at the least restrictive and most appropriate level of care. More restrictive levels of care will be used only when all other resources have been explored and deemed to be inappropriate.
The Department believes that each person, regardless of race, color, sex, age, religion, national origin, disability, sexual orientation, or marital status possesses inherent worth and value. The Department expects services to be provided in a way that shows respect and support for such diversity. Providers must be aware of the issues which may arise and ask for consultation or make referrals as needed.
Care must address family concerns and, whenever possible, involve the family in treatment planning, therapy, and transition/discharge planning. Family may include biological, step, foster, or adoptive parents; siblings or half siblings; and Sreextended family members, as appropriate. Family involvement, or lack thereof, must be documented in the clinical record. For adults who choose not to have family members involved or for whom the treating professional deems family involvement inappropriate or harmful, that information must be documented in the medical record.
Providers must encourage family members to be involved in the assessment of the client, the development of the treatment plan, and all aspects of the client's treatment unless prohibited by the client, through legal action, or because of federal confidentiality laws.
Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings.
The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends.
Care must be community-based and, when appropriate, must involve a representative from the client's community support system. This may include areas such as education, social services, law enforcement, religion, medical, and other mental health or substance abuse professionals. Community involvement must be documented in the clinical record. This documentation must include any lack of cooperation or resistance from the community support system.
Care must address the client's biological, psychological, and social development. Therapeutic interventions must be congruent with the findings of the developmental level of the client, based on comprehensive psychiatric and psychological assessments.
Providers of psychiatric services for individuals age 20 and over must be culturally competent. This includes awareness, acceptance, and respect of differences and continuing self-assessment regarding culture. Cultural competence also includes careful attention to the dynamics of differences and how they affect interactions, assumptions, and the delivery of services. Providers also demonstrate cultural competence through continuous expansion of cultural knowledge and resources through training, readings, etc., and by providing a variety of adaptations to service models in order to meet the needs of different cultural populations.
Culturally competent providers hire unbiased employees, seek advice and consultation from the minority community, and actively decide whether or not they are capable of providing services to clients from other cultures. They provide support for staff to become comfortable working in cross-cultural situations and understand the interplay between policy and practice and are committed to policies that enhance services to diverse clientele.
The treatment provider shall incorporate the needs of the "dually diagnosed" client and provide active treatment for clients with concurrent or secondary complicating problems. The "dually diagnosed" clients may have problems such as substance abuse, eating disorder symptoms, developmental delays, or mental retardation. Dual diagnosis treatment is the simultaneous and integrated treatment of coexisting disorders.
If a client is receiving services from more than one psychiatric provider, the providers must assure coordination of all services. That coordination must be documented in the client's medical record. Coordination of services is required as part of the overall treatment plan must be covered in one unified treatment plan, and is not billable as a separate service.
Refer to the Standards for Participation section in each subpart.
See 471 NAC 1-002.01F. In addition, potential out-of-state providers of Chapter 20 services must have a specific plan of how they will meet the family and community requirements. This plan must be approved by the Department to become a provider of NMAP services.
All providers participating in NMAP have agreed to provide services under the requirements of 471 NAC 2-001.03, Provider Agreements. If there is any question or concern about the quality of service being provided by an enrolled provider, the Department may perform quality assurance and utilization review activities, such as on-site visits, to verify the quality of service. If the provider or the services do not meet the standards of this chapter and the specific level of care, the provider may be subject to administrative sanctions under 471 NAC 2-002 ff. or denial of provider agreement for good cause under 471 NAC 2-001.02A. The Department may request a refund for all services not meeting Chapter 20 requirements.
If the clients are in immediate jeopardy, the sanctions may be imposed under 471 NAC 2002.05 without a hearing.
The following definitions of service apply within this chapter:
Individual Psychotherapy: A face-to-face treatment session between the client and the appropriate mental health professional for an acceptable primary psychiatric diagnosis. (No additional reimbursement is made for medication checks performed by a physician in the course of individual psychotherapy.)
Group Psychotherapy: A face-to-face treatment session, requiring professional expertise, between the client and the appropriate mental health professional in the context of a group setting of at least three and not more than twelve clients. Group psychotherapy must provide active treatment for a primary psychiatric diagnosis. NMAP does not cover: groups that are primarily supportive or educational in nature, or the services of a co-therapist.
Family Assessment: A comprehensive family assessment must be completed during the initiation of services. This must be completed by a mental health professional with training and experience in family systems.
Family Psychotherapy: A face-to-face treatment session, requiring professional expertise, between the client (identified patient), the nuclear and/or extended family, and the appropriate mental health professional. These services must focus on the family as a system and include a comprehensive family assessment. The specific objective of treatment must be to alter the family system to increase the functional level of the identified patient. This therapy must be provided with the appropriate family members and the identified patient. The focus of the services must be on systems within the family unit. Therapists of families with more than one provider must communicate with and coordinate services with any other provider for the family or individual family members. Coordination of services is required as part of the overall treatment plan and is not billable as a separate service. Duplicate or co-therapist services will not be reimbursed. The client must be eligible for NMAP and have an acceptable primary psychiatric diagnosis.
Services of Psychiatric Resident Physicians: Psychiatric resident physicians may provide psychotherapy services and medication checks when these services are directly supervised by the attending psychiatrist. The resident's supervising psychiatrist shall sign the Department approved treatment planning document for services provided by the resident physician. The resident physician may not supervise services of allied health therapists, licensed mental health practitioners, or qualified R.N.'s. Resident physician services must be billed using the appropriate CPT/HCPCS procedure codes.
Observation Room Services (23:59): When appropriate for brief crisis stabilization, outpatient hospital observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used as follows: An outpatient is defined as a person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services. NMAP covers observation room services under the following conditions:
Psychiatric therapeutic staff for adult services shall meet the following requirements:
Definition and Practice of Supervision: Supervision by the supervising practitioner is defined as the critical oversight of a treatment activity or course of action. This includes, but is not limited to, review of treatment plan and progress notes, client specific case discussion, periodic assessments of the client (as defined in each section), and diagnosis, treatment intervention or issue specific discussion. The supervising practitioner is a source of information and guidance for all members of the treatment team and their participation in services as an essential ingredient for all members of the treatment team. The critical involvement of the supervising practitioner must be reflected in the pre-treatment assessment, the treatment plan, and the interventions provided.
The supervising practitioner (or their designated and qualified substitute) must be available, in person or by telephone, to provide assistance and direction as needed during the time the services are being provided.
Supervisory contact may occur in a group setting.
Supervision is not billable by either the therapist or the supervising practitioner as it is considered a mandatory component of the care.
Psychiatric resident physicians, physician assistants and Advanced Practice Registered Nurses may not supervise allied health therapists for NMAP services.
Effective December 1, 2008, Licensed Independent Mental Health Practitioners may supervise other licensed practitioners.
The supervising practitioner shall periodically evaluate the therapeutic program and determine if treatment goals are being met and if changes in direction or emphasis are needed.
Allied health therapists include:
Payment for psychiatric services for individuals age 21 and older under NMAP is limited to payment for medically necessary psychiatric services for medically necessary primary psychiatric diagnoses.
NMAP does not pay for psychiatric services that are chronic or custodial. Psychiatric services may be covered when treating an acute exacerbation of a long-term or chronic condition. The provider shall document medical necessity and active treatment for each client. Documentation is kept in the client's medical record.
Medically necessary services are services provided at an appropriate level of care which are based on documented clinical evaluations including a comprehensive diagnostic workup and supervising practitioner-ordered treatment.
Biopsychosocially necessary treatment interventions and supplies are those which are:
Behavioral health conditions are the diagnoses listed in the current version of the Diagnostic and Statistic Manual as published by the American Psychiatric Association. (The NMAP does not reimburse for services for diagnoses of developmental disabilities, mental retardation, or V codes as part of this chapter.)
Behavioral health outcomes mean improving adaptive ability, preventing relapse or decompensation, stabilization in an emergency situation, or resolving symptoms.
Active treatment is provided under an individualized treatment plan developed by the professional staff as required for each level of care. The plan must be based on a face-to-face comprehensive evaluation of the client's restorative needs and potentialities for a primary psychiatric diagnosis. An isolated service, such as a single session with the required professional or a routine laboratory test, not furnished under a planned program of therapy or diagnosis is not active treatment even though the service was therapeutic or diagnostic in nature.
The services must be reasonably expected to improve the client's condition or to determine a psychiatric diagnosis. The treatment must, at a minimum, be designed to reduce or control the client's psychiatric symptoms to facilitate the client's movement to a less restrictive environment within a reasonable period of time.
The kinds of services that meet this requirement include individual and group psychotherapy, family therapy, drug therapy, and adjunctive therapies, such as occupational therapy, recreational therapy, and speech therapy. These services must be face-to-face to meet the active treatment criteria. The adjunctive therapeutic services must be expected to improve the client's behavioral health condition. If the only activities prescribed for the client are primarily diversional in nature, (i.e., to provide some social, educational, or recreational outlet for the patient), NMAP does not consider the services as active treatment to improve the client's behavioral health condition.
The administration of a drug or drugs does not by itself necessarily constitute active treatment (i.e., the use of mild tranquilizers, sedatives, antidepressants, or antipsychotics solely to alleviate anxiety, insomnia, depression, or psychotic symptoms).
The active treatment services must be supervised, directed, and evaluated by a supervising practitioner. The supervising practitioner's participation in the services is an essential ingredient of active treatment. The services of other qualified professionals (i.e., occupational therapists, recreational therapists, speech therapists, etc.) must be prescribed by a supervising practitioner to meet the specific needs of the client. The supervising practitioner shall evaluate the therapeutic program and determine if treatment goals are being met and if changes in direction or emphasis are needed on a regular basis through a face-to-face session, as defined for the level of care being provided. The evaluation must be based on periodic consultations and conferences with all current treatment staff, reviews of the client's clinical record, and regularly scheduled face-to-face client interviews as required for the level of care being provided.
A treatment plan must be established for each client. The treatment plan is a comprehensive plan of care formulated by the clinical staff under the direction of a supervising practitioner and is based on the individual needs of the client. The treatment plan validates the necessity and appropriateness of services and outlines the service delivery needed to meet the identified needs, reduce problem behaviors, and improve overall functioning.
The treatment plan must be based upon an assessment of the client's problems and needs in the areas of emotional, behavioral, and skills development. The treatment plan must be individualized to the client and must include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the client's progress; and the responsible professional.
The goals and objectives documented on the treatment plan must reflect the recommendations from the Initial Diagnostic Interview, the supervising practitioner and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the client's response to the treatment interventions based on the recommendations, goals and objectives.
A treatment plan must be developed for every client within the time frames specified for each type of service and must be placed in the client's clinical record. If a treatment plan is not developed within the specified time frames, services rendered may not be Medicaid reimbursable.
The treatment plan must be reviewed and updated by the treatment team according to the client's level of functioning. Minimum time frames for treatment plan reviews are dependent on the type of service. Refer to each individual service description for the review requirements. The purpose of this review is to ensure that services and treatment goals continue to be appropriate to the client's current needs, and to assess the client's progress and continued need for psychiatric services. The supervising practitioner and treatment team members shall sign and date the treatment plan at each treatment plan review.
If the client is receiving services from more than one psychiatric provider, these agencies must coordinate their services and develop one overall treatment plan for the client or family. This treatment plan is used by all providers working with the client or family.
Whenever a client is transferred from one level of care to another, transition and discharge planning must be performed and documented by the treating providers, beginning at the time of admission.
Providers shall meet the following standards regarding transition and discharge planning:
Clinical records must be arranged in a logical order such that the clinical information can be easily reviewed, audited, and copied. Each provider shall maintain accurate, complete, and timely records and shall always adhere to procedures that ensure the confidentiality of clinical data.
Treatment provided to the client must be written legibly or typed in the clinical record in a manner and with a frequency to provide a full picture of the therapies provided, as well as an assessment of the client's reaction to it. If three separate individuals cannot understand the information written in a record because of handwriting that is difficult to read, the program shall provide a readable format. Reimbursement for services may be denied if claims and/or medical records are not legible. Recoupment of previous payments for services may result if appropriate, legible, and complete records are not maintained for the client.
Providers of psychiatric services to individuals age 21 and older must comply with Department requests to review clinical records. This review may be of photocopies or on-site at the discretion of Department staff.
Under 42 CFR 456, Subpart I, the Department's inspection of care team shall periodically inspect the care and services provided to clients in any level of care under the following policies and procedures.
If, after an inspection of care is complete, the inspection of care team determines that a follow-up visit is required to ensure adequate care, a follow-up visit may be initiated by the team. This will be determined by the inspection of care team and will be noted in the inspection of care report.
The report must include the dates of the inspection and the names and qualifications of the team members. The report must not contain the names of clients; codes must be used. The facility will receive a copy of the codes.
If abuse or neglect is suspected, Medicaid staff shall make a referral to the appropriate investigative body.
If additional time is needed, the facility or provider may request an extension.
At the facility's or provider's request, copies of the facility's or provider's response will be sent to all parties who received a copy of the inspection report in 471 NAC 20-001.20H.
A return site visit may occur after the written response is received to determine if changes have completely addressed the review team's concerns from the IOC report.
The Department will take appropriate action based on confirmed documentation on inaccuracies.
Providers shall use HCPCS/CPT procedure codes when submitting claims to the Department for Medicaid services. Procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule (see 471 - 000-532).
For services in this chapter to be covered by Medicaid, the necessity of the service for the client shall be established through an Initial Diagnostic Interview. For services in this chapter to be covered by Medicaid, the client must have a diagnosable mental health disorder of sufficient duration to meet diagnostic criteria specified within the current Diagnostic and Statistics Manual of the American Psychiatric Association that results in functional impairment which substantially interferes with or limits the person's role or functioning within the family, job, school, or community. This does not include V-codes or developmental disorders.
The Initial Diagnostic Interview is used to identify the problems and needs, develop goals and objectives, and determine appropriate strategies and methods of intervention for the client. This comprehensive plan of care will be outlined in the individualized treatment plan and should reflect an understanding of how the individual's particular issues will be addressed with the service. The Initial Diagnostic Interview must occur prior to the initiation of treatment interventions and must include a baseline of the client's current functioning and treatment needs. EXCEPTION: Clients receiving acute inpatient hospital services are not required to receive an Initial Diagnostic Interview before services are initiated. Providers of the acute services must facilitate or perform the Initial Diagnostic Interview.
The licensed practitioner of the healing arts who is able to diagnose and treat major mental illness within his/her scope of practice must complete, the Initial Diagnostic Interview within four weeks of the initial session with the therapist.
Initial Diagnostic Interview
Initial Diagnostic Interviews that are incomplete will not be reimbursable.
Providers of the Initial Diagnostic Interview shall bill on claim form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). The completed Initial Diagnostic Interview must be included in the client file and available for review upon request. Failure to produce documentation of an Initial Diagnostic Interview upon request, or lack of inclusion in the client file determined during review, shall be cause for claim denial and/or refund.
Medicaid will provide reimbursement for one Initial Diagnostic Interview per treatment episode. Addendums may be included if additional information becomes available. If the client remains involved continuously in treatment for more than one year, reimbursement for an Initial Diagnostic Interview may be available annually. If the client leaves treatment prior to a successful discharge and returns for further treatment, the provider must assess the need for an addendum or a new Initial Diagnostic Interview. A second Initial Diagnostic Interview within a year must be prior authorized. Practitioners shall use national code sets to bill for this activity.
For further instructions on billing for outpatient mental health and substance abuse services, please see 471 NAC 20-002.12.
471 Neb. Admin. Code, ch. 20, § 001