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					Compliance Grid for Massachusetts Standardized Documentation Project

Individualized Action Plan
                                                                                                                                                                                                                             Please note the issues of medical
                                                                                                                                                                                                                             necessity/participation and benefit are similar for
                                                                                                                                                                                                                             both Federal and Massachusetts Medicaid as well
  See Below for additional comments                                                                                                                                                MCD/CARE Requirements                     as for Medicare

                                                      State payer requirements              Managed Care                Accreditation Issues                                        This helps make the case for:



No. on                                         MEDICAID               DPH                             State   JCAHO                                                              Medical       Client
 form
                       Element                  / DMA
                                                          DMH *
                                                                      BSAS
                                                                                DPH HCQ    MBHP
                                                                                                      MCO's     **
                                                                                                                           COA     CARF         NCQA       Medicare Medicaid
                                                                                                                                                                                Necessity   Participation
                                                                                                                                                                                                            Client Benefit                      Comments

         Client Name (First, MI, Last):        429.436;                                   One form     AT     IM.6.20     RPM 7                   NO                2500.2(A)                                                MBHP requires one form of ID on each page
                                               434.410                                     of ID on                                            Citations                                                                     chosen from either ID #, Date of Birth or
                                                                                          each page                                                                                                                          Name. *DMH citations are based on the
                                                                                                                                                                                                                             June 13, 1996 Rehab Option Tool. **
                                                                                                                                                                                                                             JCAHO: Behavioral Health Care Manual -
                                                                                                                                                                                                                             PC =Provision of Care, Treatment and
                                                                                                                                                                                                                             Services Section; MM = medication
                                                                                                                                                                                                                             management; IM = Management of
                                                                                                                                                                                                                             Information. COA:
  1
         Second form of Client ID                                                                             IM.6.20                                               2500.2(A)

  2
         Start date of treatment plan                     3.2:00 R     105                             AT     IM.6.20
                                                                      CMR
                                                                        SA
                                                                     162.405(
  3                                                                    B)(6)
         Assessed needs and treatment                     3.3:00 R      105     105 CMR MBHP AT        AT     PC.4.20      COA    2.C.2.a.                  LCDs    4221(B)        P                              P
         preferences as linked to assessment                           CMR 140.520 C                                      Service
         and outcomes                                                  OTP        (2)(a)                                 Standard
                                                                     750.520(                                            s CFD 4;
                                                                         C)                                               DTX 4;
                                                                        SA                                                FPS 4;
                                                                     162.405(                                             GLS 4;
                                                                         A)                                                MH 3;
                                                                        SA                                                RTX 4;
                                                                     162.405(                                             SCL 4;
                                                                       B)(1)                                               YIL 5
                                                                     *8.12(f)(4
                                                                          )
  4
         Legal requirements and/or required                                                                   PC.6.170             2.C.3.f.                                                                                  Legal requirements as they relate to
         restitution                                                                                                                                                                                                         treatment including any restitution, e.g. court
                                                                                                                                                                                                                             ordered treatment. JCAHO: Interaction w/the
                                                                                                                                                                                                                             criminal or juvenile justice system if
  5                                                                                                                                                                                                                          applicable
         Target Completion Dates and/or                   3.4:00 R                        MBHP AT      AT     PC.4.40             2.C.3.b.(                         4221(B)                                                  MBHP Audit Tooi and DPH regulations look
         modified dates                                                                                                              9)                                                                                      for timelines for attainment. These would
                                                                                                                                                                                                                             need to reflect any adjustments to treatment
                                                                                                                                                                                                                             plan as well. DMH Rehab Option 3.4:00
                                                                                                                                                                                                                             includes a baseline level of functioning and
                                                                                                                                                                                                                             includes "significant issues that (may)
                                                                                                                                                                                                                             impede attainment of identified goals,
                                                                                                                                                                                                                             addressed within the context of the
                                                                                                                                                                                                                             treatment plan.
  6




                                                                                                                              Page 1
Compliance Grid for Massachusetts Standardized Documentation Project

Individualized Action Plan
                                                                                                                                                                                                                   Please note the issues of medical
                                                                                                                                                                                                                   necessity/participation and benefit are similar for
                                                                                                                                                                                                                   both Federal and Massachusetts Medicaid as well
  See Below for additional comments                                                                                                                                      MCD/CARE Requirements                     as for Medicare

                                                    State payer requirements              Managed Care              Accreditation Issues                                  This helps make the case for:



No. on                                       MEDICAID               DPH                           State   JCAHO                                                        Medical       Client
 form
                       Element                / DMA
                                                        DMH *
                                                                    BSAS
                                                                              DPH HCQ    MBHP
                                                                                                  MCO's     **
                                                                                                                       COA      CARF       NCQA   Medicare Medicaid
                                                                                                                                                                      Necessity   Participation
                                                                                                                                                                                                  Client Benefit                      Comments

         Goal                                 429.436   3.4:00 R      105     105 CMR MBHP AT      AT     PC.4.40      RPM    2.C.3.a.             L541    4221(B)`      P                                         DPH doesn't use the term objectives but
                                                                     CMR 140.520 C                                     7.02                                                                                        instead references short term and long term
                                                                     OTP        (2) c                                  COA                                                                                         goals.
                                                                   750.520(                                           Service
                                                                       D)                                            Standard
                                                                   *8.12(f)(4                                        s CFD 4;
                                                                        )                                             DTX 4;
                                                                                                                      FPS 4;
                                                                                                                      GLS 4;
                                                                                                                       MH 3;
                                                                                                                      RTX 4;
                                                                                                                      SCL 4;
                                                                                                                       YIL 5
  7
         Desired Results in client's words                           105                                                      2.C.3.a.(                                                P                           Additional evidence of client participation in
                                                                    CMR                                                          1)                                                                                development of the plan.
                                                                     OTP
                                                                   750.520(
                                                                      C)
                                                                      SA
                                                                   162.405(
  8                                                                  B)(4)
         Strengths and skills                           3.4:00 R     105    105 CMR MBHP AT        AT     PC.4.40      COA    2.C.3.a.(                                                s                           DMH requires skills and strengths relate to
                                                                    CMR     140.520 C                                 Service   5)(a)                                                                              each objective/goal. The other payers are
                                                                      SA      (2) (d)                                Standard                                                                                      not as specific in their requirements.
                                                                   162.405(                                          s CFD 4;
                                                                     B)(2)                                            DTX 4;
                                                                                                                      FPS 4;
                                                                                                                      GLS 4;
                                                                                                                       MH 3;
                                                                                                                      RTX 4;
                                                                                                                      SCL 4;
                                                                                                                       YIL 5
  9
         Individualized, measurable and                 3.4:00 R     105                MBHP AT    AT     PC.4.40      RPM    2.C.3.b.             L541;   4221(B)       P                              P
         behaviorally stated objective(s)                           CMR                                                7.02                        L3239
                                                                      SA                                               COA
                                                                   162.405(                                           Service
                                                                     B)(3)                                           Standard
                                                                                                                     s CFD 4;
                                                                                                                      DTX 4;
                                                                                                                      FPS 4;
                                                                                                                      GLS 4;
                                                                                                                       MH 3;
                                                                                                                      RTX 4;
                                                                                                                      SCL 4;
                                                                                                                       YIL 5
 10
         Anticipated Duration of treatment    429.436                105    105 CMR                AT                         2.C.3.b.(            L541
                                                                    CMR     140.520 C                                            9)
                                                                     OTP      (2) c
                                                                   750.520(
                                                                      D)
                                                                      SA
                                                                   162.405(
 11                                                                  B)(6)


                                                                                                                          Page 2
Compliance Grid for Massachusetts Standardized Documentation Project

Individualized Action Plan
                                                                                                                                                                                                                    Please note the issues of medical
                                                                                                                                                                                                                    necessity/participation and benefit are similar for
                                                                                                                                                                                                                    both Federal and Massachusetts Medicaid as well
  See Below for additional comments                                                                                                                                       MCD/CARE Requirements                     as for Medicare

                                                       State payer requirements            Managed Care              Accreditation Issues                                  This helps make the case for:



No. on                                          MEDICAID               DPH                         State   JCAHO                                                        Medical       Client
 form
                       Element                   / DMA
                                                           DMH *
                                                                       BSAS
                                                                                 DPH HCQ   MBHP
                                                                                                   MCO's     **
                                                                                                                        COA      CARF       NCQA   Medicare Medicaid
                                                                                                                                                                       Necessity   Participation
                                                                                                                                                                                                   Client Benefit                      Comments

         Therapeutic Intervention/ Service      429.436;   3.4:00 R      105     105 CMR MBHP AT    AT     PC.4.40      COA    2.C.2.e.             L541    4221 (B)      P                                         This may include services provided by
         Description/ Frequency/ Duration/      434.410                 CMR 140.520 C                                  Service & 2.C.3.c-                                                                           others if the provider is responsible for
         Provider including anticipated                                 OTP       (2) (e)                             Standard    d&                                                                                monitoring the delivery of those services.
         collateral and consultation contacts                         750.520(                                        s CFD 4; 2.c.2.d                                                                              JCAHO: Case management services,
                                                                          D)                                           DTX 4;                                                                                       community integration services, activity
                                                                         SA                                            FPS 4;                                                                                       services, peer services, other services not
                                                                      162.405(                                         GLS 4;                                                                                       provided by agency. Client education needs
                                                                        B)(5)                                           MH 3;                                                                                       re: basic health, safety, diet, oral health, etc
                                                                      *8.12(f)(4                                       RTX 4;                                                                                       also considered.
                                                                           )                                           SCL 4;
                                                                                                                        YIL 5
 12
         Discharge Plan, After-care plan,        429.436                105    105 CMR              AT     PC.15.10     RPM       2.D.              L541    4221(B)       P                                         Medicaid in the SMM calls these treatment
         Discharge criteria                                            CMR     140.520 C                      &         7.02                                                                                        objectives.
                                                                        OTP      (2) (a)                   PC.15.20     COA
                                                                      750.520(                                         Service
                                                                         D)                                           Standard
                                                                         SA                                           s CFD 4;
                                                                      162.405(                                         DTX 4;
                                                                        B)(8)                                          FPS 4;
                                                                                                                       GLS 4;
                                                                                                                        MH 3;
                                                                                                                       RTX 4;
                                                                                                                       SCL 4;
                                                                                                                        YIL 5
 13
         Anticipated Date of Discharge                                                                     PC.15.20
 14
         Client Signature/ Date                    h       3.5:00 R     105                                PC.4.50      RPM      2.c.1                                                  P                           No payers require a client signature.
                                                                       CMR                                              7.02                                                                                        However, most accreditors require evidence
                                                                        OTP                                             COA                                                                                         of client participation and review of the
                                                                      750.520(                                         Service                                                                                      treatment plan. BSAS requires evidence of
                                                                         D)                                           Standard                                                                                      client participation in development of plan
                                                                         SA                                           s CFD 4;                                                                                      and suggests that the signature may be one
                                                                      162.405(                                         DTX 4;                                                                                       way to provide this evidence. Date provides
                                                                        B)(7)                                          FPS 4;                                                                                       evidence that treatment plan is current.
                                                                                                                       GLS 4;                                                                                       JCAHO requires clients involvement,
                                                                                                                        MH 3;                                                                                       signature may be used but doesn't testify to
                                                                                                                       RTX 4;                                                                                       the degree of involvement, understanding or
                                                                                                                       SCL 4;                                                                                       agreement. Need DMH data still
                                                                                                                        YIL 5

 15
         Parent/Guardian Signature (If                     3.5:00 R                                                     RPM      2.c.1                                                  P                           See comment above under #15.
         applicable)/Date                                                                                               7.02
                                                                                                                        COA
                                                                                                                       Service
                                                                                                                      Standard
                                                                                                                      s CFD 4;
                                                                                                                       DTX 4;
                                                                                                                       FPS 4;
                                                                                                                       GLS 4;
                                                                                                                        MH 3;
                                                                                                                       RTX 4;
                                                                                                                       SCL 4;
                                                                                                                        YIL 5
 16

                                                                                                                           Page 3
Compliance Grid for Massachusetts Standardized Documentation Project

Individualized Action Plan
                                                                                                                                                                                                                      Please note the issues of medical
                                                                                                                                                                                                                      necessity/participation and benefit are similar for
                                                                                                                                                                                                                      both Federal and Massachusetts Medicaid as well
  See Below for additional comments                                                                                                                                         MCD/CARE Requirements                     as for Medicare

                                                          State payer requirements             Managed Care            Accreditation Issues                                  This helps make the case for:



No. on                                             MEDICAID                DPH                         State   JCAHO                                                      Medical       Client
 form
                       Element                      / DMA
                                                               DMH *
                                                                           BSAS
                                                                                     DPH HCQ   MBHP
                                                                                                       MCO's     **
                                                                                                                          COA     CARF        NCQA   Medicare Medicaid
                                                                                                                                                                         Necessity   Participation
                                                                                                                                                                                                     Client Benefit                      Comments

         Primary Provider Signature/                           3.5:00 R     105    105 CMR MBHP AT      AT
         Credential/ Date                                                  CMR     140.520 C
                                                                             SA      (2) (g)
                                                                          162.405(
 17                                                                         B)(7)
         Psychiatrist Signature (if applicable)/                            105                                                                               4320(B)                                                 SMM calls this 'physician direction" and
         Date                                                              CMR                                                                                4221(B)                                                 requires this for clinics. SMM on Outpt
                                                                            SA                                                                                                                                        psychiatric services requires the plan be
                                                                          162.405(                                                                                                                                    developed by an evaluation team which
                                                                             A)                                                                                                                                       must include at a minimum a psychiatrist.
 18
         Two other signatures for MDT if            429.435                                                                                                                                                           See above comment. The "team" requires
         applicable if provider does not meet                                                                                                                                                                         an MD and someone who can diagnose
         requirements to be a member of MDT.                                                                                                                                                                          mental illness. These two positions on the
                                                                                                                                                                                                                      team can be held by one person which
                                                                                                                                                                                                                      would have to be the MD.
 19

                                                                 Treatment Planning
                                                                   Documentation:
                                                              1. This grid assumes that there is a usually a separate progress note written to descibe the
                                                              treatment planning session in order to support a claim and/or to describe the client's/family
                                                              participation in the development of the treatment plan. However, DMH residential providers do
                                                              not bill for contact hours and generally will include this treatment planning information in a short
                                                              contact note and/or check marks indiccating the review of the treatment plan with the client and
                                                              the client's agreement. Some outpatient programs have check marks on their treatment plans as
                                                              well to indicate participation. If a progress note is written, the date of the progress note
                                                              describing this meeting should be listed on the treatment plan somewhere so that it can be easily
                                                              located. 2. Where an audit tool developed by the payer was more specific than the regulations,
                                                              we cited the tool with an AT in the cell.




                                                                                                                             Page 4
         OPIOD TREATMENT
         PROGRAM ADD ONS                              State payer requirements          Managed Care          Accreditation Issues                            This helps make the case for:

No. on                                          MEDICAID            DPH                         State                                                        Medical     Client       Client
 form
                      Element                    / DMA
                                                           DMH
                                                                    BSAS
                                                                              DPH HCQ   MBHP
                                                                                                MCO's
                                                                                                        JCAHO      COA   CARF    NCQA   Medicare   Medicaid
                                                                                                                                                            Necessity Participation   Benefit
                                                                                                                                                                                                               Comments

     1   How is concurrent abuse of other                                                               PC.4.20
         drugs going to be managed?

     2   D/C planning addresses relapse                                                                 PC.15.20
         prevention and administrative
         w/drawal
     3   Prescription medication, prescribed                       105 CMR
         dosages, plans for changing                                  SA
         medications                                               162.405(
                                                                     B)(9)
                                                                     OTP
                                                                   750.520(
                                                                      D)


     4   Planned rate of detoxification when                       105 CMR
         applicable                                                   SA
                                                                   162.405(
                                                                     B)(9)
                                                                     OTP
                                                                   750.520(
                                                                      D)


     5   Treatment optionsfor client ro reach                      105 CMR                                                                                                                      Narcotic Treatment Programs only
         his/her highest level of funtioning                          SA
         and documentation, justification                          162.405(
         and evaluation of dosages every 90                         B)(10)
         days
     6   Documenation of disability, if any,                       105 CMR
         which requires a modification of                             SA
         policies or practices and record of                       162.405(
         modifications                                              B)(10)
Periodic Treatment Plan
Reviews Requirements                            *** DMA and DMH guidelines used to develop this list
  1   Evidence of client participation
  2   Review of progress
  3   If progress not met, analysis
  4   consumer's goals and objectives
      revised, if needed
  5 Updated statement of problems, goals,
      and treatment activities and, if
      indicated, a reformulation of treatment
      plan.
  6 Names and titles of participants
  7 Space for guardian signature.
  8 MDT Review and signatures

				
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