N.Y. Comp. Codes R. & Regs. tit. 14 § 588.6

Current through Register Vol. 46, No. 43, October 23, 2024

Section 588.6 - Standards pertaining to reimbursement for clinic treatment programs

(a) Clinic treatment programs shall receive reimbursement for the following types of visits:

(1) Brief visit: shall be reimbursed for services of at least 15 minutes in duration but not more than 29 minutes of face-to-face interaction between one recipient and one therapist.

(2) Regular visit: shall be reimbursed for services of at least 30 minutes in duration of face-to-face interaction between one recipient and one therapist.

(3) Crisis visit: shall be reimbursed for services of at least 30 minutes in duration of face-to-face interaction between one recipient and one therapist.

(4) Group therapy visits: shall be reimbursed for services of at least 60 minutes duration provided to from 2 to 12 recipients and a therapist(s).

(5) Collateral visit: shall be reimbursed for:

(i) clinical support services of at least 30 minutes in duration of face-to-face interaction between one or more collaterals and one therapist with or without a recipient; or

(ii) family treatment services of at least 30 minutes in duration of face-to-face interaction among all of the following: a recipient, one or more family members, and a therapist.

(6) Group collateral visit: shall be reimbursed for:

(i) clinical support services, as defined in section 587.4(c)(5) of this Title, of at least 60 minutes in duration but not more than two hours and shall represent services to more than one recipient and/or his or her collaterals. Such visits need not include recipients but shall not include more than 12 collaterals and/or recipients in a face-to-face interaction with a therapist for which reimbursement is claimed. Such limitation does not preclude the non-reimbursed participation of additional persons in the group session but such participation shall not be separately reimbursed; or

(ii) family treatment services of at least 60 minutes in duration but not more than two hours and shall include services to more than one recipient. For each recipient participant, at least one family member shall participate. However, only one group collateral bill per recipient is allowed per day. Such visits shall not include more than 12 participants, including recipients and family members, for which reimbursement is claimed. Such limitation does not preclude the non-reimbursed participation of additional persons in the group session.

(7) Family visit: Shall be reimbursed for family treatment services, as defined in section 587.4(c) of this Title, of at least 60 minutes in duration of face-to-face interaction between one recipient, one or more of his or her family members, and one therapist. For purposes of billing family visits which meet these criteria, providers shall bill one regular visit and one collateral visit.

(b) The utilization review authority designated pursuant to section 587.6 of this Title shall conduct the following reviews regarding, at a minimum, a random 25 percent sample of recipients:

(1) a review of the appropriateness of admission to a clinic treatment program within 30 days after admission;

(2) a review of the need for continued treatment in a clinic treatment program within seven months after admission and every six months thereafter unless the recipient is:

(i) discharged out of the program and subsequently readmitted, wherein the cycle begins again; or

(ii) receiving medication therapy and medication education services only, wherein the need for continued treatment shall be reviewed every 12 months thereafter.

(c) The need for continued clinic treatment service beyond 40 visits per benefit year for adults in clinic treatment programs shall be determined, in accordance with subdivisions (e) and (f) of this section, no later than at the 40th visit during a benefit year, including 20 collateral and/or group collateral visits. Such determination shall include an estimate of the number of visits beyond 40 required for the recipient within the remaining benefit year. The need for continued clinic treatment service beyond this estimated number of visits shall be determined at or prior to the provision of the estimated number of visits during the benefit year. The need for any additional revised estimates shall be determined accordingly.

(d) The need for continued clinic treatment services beyond 40 visits per benefit year for children with a diagnosis of emotional disturbance in clinic treatment programs shall be determined, in accordance with subdivisions (e) and (f) of this section, no later than at the 40th visit during a benefit year. Such determination shall include an estimate of the number of visits beyond 40 required for the recipient within the remaining benefit year. The need for continued clinic treatment service beyond this estimated number of visits shall be determined at or prior to the provision of the estimated number of visits during the benefit year. The need of any additional revised estimates shall be determined accordingly.

(e) Determinations required in accordance with subdivisions (c) and (d) of this section shall be:

(1) completed by the treating clinician;

(2) documented in the case record; and

(3) reviewable by the Office of Mental Health or its designated agent.

(f) The determination of need for admission to or continued treatment in a clinic treatment program, in accordance with subdivisions (b)-(d) of this section, shall take the following criteria into account:

(1) the recipient's history, diagnosis, prognosis, progress or lack thereof; and

(2) the availability of a viable alternative program; or

(3) the receipt of clozapine medication therapy; or

(4) for adults, service mandated by an order of conditions issued pursuant to section 330.20 of the Criminal Procedure Law; or

(5) for children, that a recipient would be unable to continue functioning in the family setting.

(g) The treatment plan required pursuant to section 587.16 of this Title shall be developed prior to the fourth visit after admission or within 30 days of admission, whichever comes first. Review of the treatment plan shall be every three months, unless the individual is discharged and readmitted, in which case the review cycle begins again.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 588.6