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					Rehabilitative Services for Persons with Mental Illness                                               Section II

    SECTION II - REHABILITATIVE SERVICES FOR PERSONS WITH
                 MENTAL ILLNESS (RSPMI)
                     CONTENTS
    200.000          REHABILITATIVE SERVICES FOR PERSONS WITH MENTAL ILLNESS (RSPMI)
                     GENERAL INFORMATION
        201.000      Introduction
        202.000      Arkansas Medicaid Participation Requirements for RSPMI
        202.100      Certification Requirements by the Division of Behavioral Health Services (DBHS)
        202.200      Providers with Multiple Sites
    210.000          PROGRAM COVERAGE
        211.000      Coverage of Services
        212.000      Quality Assurance
        213.000      Staff Requirements
        213.100      Mental Health Paraprofessional Training
        214.000      Facility Requirements
        215.000      Non-Refusal Requirement
        216.000      Scope
        217.000      RSPMI Program Entry
        217.100      Primary Care Physician (PCP) Referral
        217.101      Youth Outcome Questionnaire (YOQ®)
        217.111      Procedure Codes Not Requiring PCP Referral for Beneficiaries Under Age 21
        217.112      Medicaid Eligible at the Time the Service is Provided
        217.113      Medicaid Ineligible at the Time the Service is Provided
        218.000      Master Treatment Plan
        218.100      Periodic Treatment Plan Review
        218.101      Participation of Families and Children in the Periodic Review of the Treatment Plan
                     for Children Under Age 21
        219.000      Covered Services
        219.100      Outpatient Services
        219.110      Daily Limit of Beneficiary Services
        219.130      Routine Venipuncture for Collection of Specimen
        219.140      Telemedicine (Interactive Electronic Transactions) RSPMI Services
        219.141      Services Available to Residents of Long Term Care Facilities
        220.000      Inpatient Hospital Services
        220.100      Hospital Visits
        220.200      Inpatient Hospital Services Benefit Limit
        221.000      Medicaid Utilization Management Program (MUMP)
        221.100      MUMP Applicability
        221.110      MUMP Exemptions
        221.200      MUMP Procedures
        221.210      Direct Admissions
        221.220      Transfer Admissions
        221.230      Retroactive Eligibility
        221.240      Third Party and Medicare Primary Claims
        221.250      Request for Reconsideration
        221.260      Post-Payment Review
        222.000      Approved Service Locations
        223.000      Exclusions
        224.000      Physician’s Role
        224.100      Physician’s Role for Adults Age 21 and Over
        224.200      Physician’s Role for Children Under Age 21
        224.201      Psychiatric Diagnostic Assessment
        225.000      Diagnosis and Clinical Impression
        226.000      Documentation/Record Keeping Requirements
        226.100      Reserved
                                                                                                    Section II-1
Rehabilitative Services for Persons with Mental Illness                                                 Section II

        226.200      Documentation
        227.000      Medical Necessity
        227.001      Prescription for RSPMI Services
        227.100      Prescription for Speech Therapy
        227.110      Procedures for Obtaining Extension of Benefits for Speech Therapy
        227.111      Reconsideration of Extension of Benefits Denial
        227.112      Appealing an Adverse Action
        228.000      Provider Reviews
        228.100      Reserved
        228.200      Reserved
        228.300      Record Reviews
        228.310      On-Site Inspections of Care (IOC)
        228.311      Purpose of the Review
        228.312      Provider Notification of IOC
        228.313      Information Available Upon Arrival of the IOC Team
        228.314      Cases Chosen for Review
        228.315      Program Activity Observation
        228.316      Beneficiary Interviews
        228.317      Exit Conference
        228.318      Written Reports
        228.319      Corrective Action Plans
        228.320      Other Actions
        228.330      Retrospective Reviews
        228.331      Purpose of the Review
        228.332      Cases Chosen for Review
        228.333      Review Report
        228.334      Reconsideration
        228.335      Recoupments
        228.400      Retrospective Review of Speech Therapy Services for Individuals Under Age 21
        228.410      Speech-Language Therapy Guidelines for Retrospective Review
        228.411      Reserved
        228.412      Reserved
        228.413      Reserved
        228.414      Accepted Tests for Speech-Language Therapy
        228.415      Intelligence Quotient (IQ) Testing
        228.416      Recoupment Process
        229.000      Medicaid Beneficiary Appeal Process
        229.100      Electronic Signatures
    230.000          PRIOR AUTHORIZATION (PA) AND EXTENSION OF BENEFITS
        231.000      Introduction to Prior Authorization and Extension of Benefits
        231.100      Prior Authorization and Extension of Benefits
    240.000          REIMBURSEMENT
        241.000      Rate Appeal Process
    250.000          BILLING PROCEDURES
        251.000      Introduction to Billing
        252.000      CMS-1500 Billing Procedures
        252.100      Procedure Codes for Types of Covered Services
        252.110      Outpatient Procedure Codes
        252.130      Inpatient Hospital Procedure Codes
        252.140      Telemedicine RSPMI Services Billing Information
        252.150      Services Available to Residents of Long Term Care Facilities Billing Information
        252.200      Place of Service Codes
        252.300      Billing Instructions - Paper Only
        252.310      Completion of the CMS-1500 Claim Form
        252.400      Special Billing Procedures

                                                                                                    Section II-2
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        252.410      RSPMI Billing Instructions
        252.420      Non-Covered Diagnosis Codes
        252.430      Daily Service Billing Exclusions

    200.000          REHABILITATIVE SERVICES FOR PERSONS WITH
                     MENTAL ILLNESS (RSPMI) GENERAL INFORMATION

    201.000          Introduction                                                                   10-5-09

        Medicaid (Medical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining
        medical care within the guidelines specified in Section I of this manual. Rehabilitative Services
        for Persons with Mental Illness (RSPMI) are covered by Medicaid when provided to eligible
        Medicaid beneficiaries by enrolled providers.
        RSPMI may be provided to eligible Medicaid beneficiaries at all provider facility certified sites.
        Acceptable allowable places of service are found in the service definitions located in Section
        252.110.

    202.000          Arkansas Medicaid Participation Requirements for RSPMI                         10-4-09

        In order to ensure quality and continuity of care, all mental health providers approved to receive
        Medicaid reimbursement for services to Medicaid beneficiaries must meet specific qualifications
        for their services and staff. Providers with multiple service sites must enroll each site separately
        and reflect the actual service site on billing claims.
        RSPMI providers must meet the Provider Participation and enrollment requirements contained
        within Section 140.000 of this manual as well as the following criteria to be eligible to participate
        in the Arkansas Medicaid Program:
        A.    Providers must be located within the State of Arkansas.

        B.    A provider must be certified by the Division of Behavioral Health Services (DBHS). (See
              Section 202.100 for certification requirements.)

        C.    A copy of the current DBHS certification as an RSPMI provider must accompany the
              provider application and Medicaid contract.

        DMS shall exclude providers for the reasons stated in 42 U.S.C. §1320a-7(a) and
        implementing regulations and may exclude providers for the reasons stated in 42 U.S.C.
        §1320a-7(b) and implementing regulations. The following factors shall be considered by DHS
        in determining whether sanction(s) should be imposed:
        A.    Seriousness of the offense(s)

        B.    Extent of violation(s)

        C.    History of prior violation(s)

        D.    Whether an indictment or information was filed against the provider or a related party as
              defined in DHS Policy 1088, titled DHS Participant Exclusion Rule.

    202.100          Certification Requirements by the Division of Behavioral Health                11-1-08
                     Services (DBHS)

        Providers of RSPMI Services must furnish documentation of certification from the Division of
        Behavioral Health Services (DBHS) establishing that the provider is accredited by the Joint
        Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on
        Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA), or other
        national accreditation approved by DBHS and that the accreditation encompasses the RSPMI

                                                                                                       Section II-3
Rehabilitative Services for Persons with Mental Illness                                                   Section II

        services to be furnished. Providers must meet all other certification requirements in addition to
        accreditation.
        Certification requirements may be found at www.arkansas.gov/dhs/dmhs/.

    202.200          Providers with Multiple Sites                                                    11-1-08

        Providers with multiple service sites must apply for enrollment for each site. A cover letter must
        accompany the provider application for enrollment of each site that attests to their satellite status
        and the name, address and Arkansas Medicaid number of the parent organization.

        A letter of attestation must be submitted to the Medicaid Enrollment Unit by the parent
        organization annually that lists the name, address and Arkansas Medicaid number of each site
        affiliated with the parent. The attestation letter must be received by Arkansas Medicaid no later
        than June 15 of each year beginning in June 2009.
        Failure by the parent organization to submit a letter of attestation by June 15 each year may
        result in the loss of Medicaid enrollment. The Enrollment Unit will verify the receipt of all required
        letters of attestation by July 1 of each year. A notice will be sent to any parent organization if a
        letter is not received advising of the impending loss of Medicaid enrollment.


    210.000          PROGRAM COVERAGE

    211.000          Coverage of Services                                                             10-4-09

        Rehabilitative Services for Persons with Mental Illness (RSPMI) are limited to certified providers
        who offer core mental health services for the treatment and prevention of mental disorders. The
        provider must be certified as an RSPMI provider by the Division of Behavioral Health Services.
        An RSPMI provider must have 24-hour emergency response capability to meet the emergency
        treatment needs of the RSPMI clients they are serving. The provider must implement and
        maintain a written policy reflecting the specific coverage plan to meet this requirement. An
        answering machine message to call 911 or report to the nearest emergency room in and of itself
        is not sufficient to meet the requirement.

    212.000          Quality Assurance                                                              10-13-03

        Each RSPMI provider must establish and maintain a quality assurance committee that will
        examine the clinical records for completeness, adequacy and appropriateness of care, quality of
        care and efficient utilization of provider resources. The quality assurance documentation should
        be filed separately from the clinical records.

    213.000          Staff Requirements                                                               8-15-08

        Each RSPMI provider shall ensure that mental health professionals are available to provide
        appropriate and adequate supervision of all clinical activities. RSPMI staff members must
        provide services only within the scope of their individual licensure. It is the responsibility of the
        facility to credential each clinical staff member, specifying the areas in which he or she can
        practice based on training, experience and demonstrated competence.

        Minimal staff requirements for RSPMI provider participation in the Arkansas Medicaid Program
        are:
        A.    A Chief Executive Officer (CEO) with professional qualifications and experience as
              established by the provider’s governing body.

        B.    Appropriate mental health professionals who shall meet all professional requirements as
              defined in the state licensing and certification laws relating to their respective professions.
              Mental health professionals include the following:

                                                                                                        Section II-4
Rehabilitative Services for Persons with Mental Illness                                                   Section II

              1.     Psychiatrist,
              2.     Physician,
              3.     Psychologist,
              4.     Psychological Examiner,
              5.     Adult Psychiatric Mental Health Clinical Nurse Specialist,
              6.     Child Psychiatric Mental Health Clinical Nurse Specialist,
              7.     Adult Psychiatric Mental Health Advanced Nurse Practitioner,
              8.     Family Psychiatric Mental Health Advanced Nurse Practitioner,
              9.     Master of Social Work (Licensed in the State of Arkansas),
              10.    Registered nurse (RN; licensed in the State of Arkansas) who has one (1) year
                     supervised experience in a mental health setting (Services provided by the RN must
                     be within the scope of practice specified by the RN’s licensure.),
              11.    Licensed professional counselor (Licensed in the State of Arkansas) and
              12.    Persons in a related profession who are licensed in the State of Arkansas and
                     practicing within the bounds of their licensing authority, with a master's degree and
                     appropriate experience in a mental health setting, including documented, supervised
                     training and experience in diagnosis and therapy of a broad range of mental
                     disorders.
        C.    The services of a medical records librarian are required. The medical records librarian (or
              person performing the duties of the medical records librarian) shall be responsible for
              ongoing quality controls, for continuity of patient care and patient traffic flow. The librarian
              shall assure that records are maintained, completed and preserved; that required indexes
              and registries are maintained and that statistical reports are prepared. This staff member
              will be personally responsible for ensuring that information on enrolled patients is
              immediately retrievable, establishing a central records index, and maintaining service
              records in such a manner as to enable a constant monitoring of continuity of care.

        D.    A mental health paraprofessional is defined as a person with a Bachelor's Degree or a
              license from the Arkansas State Board of Nursing who does not meet the definition of
              mental health professional, but who is licensed and certified by the State of Arkansas in a
              related profession and is practicing within the bounds as permitted by his or her licensing
              authority, or a person employed by a certified RSPMI provider with a high school diploma
              or general equivalency diploma (GED) and documented training in the area of mental
              health. A mental health paraprofessional may provide certain Rehabilitative Services for
              Persons with Mental Illness under supervision of a mental health professional. The
              services paraprofessionals may provide are: crisis stabilization intervention, on-site
              intervention, off-site intervention, rehabilitative day service, therapeutic day/acute day
              treatment and collateral service. If the paraprofessional is a licensed nurse, the approved
              services may also be provided: medication administration by a licensed nurse, routine
              venipuncture for collection of specimen and catheterization for collection of specimen.

        Effective for dates of service on and after October 1, 2008, when an RSPMI provider files a claim
        with Arkansas Medicaid, the staff member who actually performed the service on behalf of the
        RSPMI provider must be identified on the claim as the performing provider. RSPMI staff
        members who are eligible to enroll in the Arkansas Medicaid program have the option of either
        enrolling or requesting a Practitioner Identification Number (View or print form DMS-7708) so
        that they can be identified on claims. For example, an LCSW may choose to enroll in the
        Licensed Mental Health Practitioners program or choose to obtain a Practitioner Identification
        Number.




                                                                                                        Section II-5
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        This action is taken in compliance with the federal Improper Payments Information Act of 2002
        (IPIA), Public Law 107-300 and the resulting Payment Error Rate Measurement (PERM)
        program initiated by the Centers for Medicare and Medicaid Services (CMS).

        Certain types of practitioners who perform services on behalf of an RSPMI provider cannot enroll
        in the Arkansas Medicaid program. These practitioners must request a Practitioner Identification
        Number so that they can be identified on claims:

                         Psychological Examiner
                         Adult Psychiatric Mental Health Clinical Nurse Specialist
                         Child Psychiatric Mental Health Clinical Nurse Specialist
                         Adult Psychiatric Mental Health Advanced Nurse Practitioner
                         Family Psychiatric Mental Health Advanced Nurse Practitioner
                         Master of Social Work (Licensed in the State of Arkansas)
                         Registered nurse
                         Paraprofessional

    213.100             Mental Health Paraprofessional Training                                      8-1-05

        The RSPMI provider is responsible for ensuring all mental health paraprofessionals successfully
        complete training in mental health service provision from a licensed medical person experienced
        in the area of mental health, a certified RSPMI Medicaid provider, or a facility licensed by the
        State Board of Education before providing care to Medicaid beneficiaries.
        A.    The mental health paraprofessional must receive orientation to the RSPMI provider
              agency.

        B.    The mental health paraprofessional training course must total a minimum of forty (40)
              classroom hours and must be successfully completed within a maximum time of the first
              two (2) months of employment by the RSPMI provider agency.

        C.    The training curriculum must contain information specific to the population being served,
              i.e. child and adolescent, adult, dually diagnosed, etc. The curriculum must include, but is
              not limited to:
              1.        Communication skills.
              2.        Knowledge of mental illnesses.
              3.        How to be an appropriate role model.
              4.        Behavior management.
              5.        Handling emergencies.
              6.        Record keeping: observing beneficiary, reporting or recording observations, time, or
                        employment records.
              7.        Knowledge of clinical limitations.
              8.        Knowledge of appropriate relationships with beneficiary.
              9.        Group interaction.
              10.       Identification of real issues.
              11.       Listening techniques.
              12.       Confidentiality.
              13.       Knowledge of medications and side effects.

                                                                                                       Section II-6
Rehabilitative Services for Persons with Mental Illness                                                 Section II

              14.    Daily living skills.
              15.    Hospitalization procedures single-point-of-entry.
              16.    Knowledge of the Supplemental Security Income (SSI) application process.
              17.    Knowledge of day treatment models proper placement levels.
              18.    Awareness of options.
              19.    Cultural competency.
              20.    Ethical issues in practice.
              21.    Childhood development, if serving the child and adolescent population.
        D.    A written examination of the mental health paraprofessional’s knowledge of the 40-hour
              classroom training curriculum must be successfully completed.

        E.    Evaluation of the mental health paraprofessional’s ability to perform daily living skills (DLS)
              for mental health services must be successfully completed by means of a skills test.

        F.    The paraprofessional who successfully completes the training must be awarded a
              certificate. This certificate must state the person is qualified to work in an agency under
              professional supervision as a mental health paraprofessional.

        G.    In-service training sessions are required at a minimum of once per 12-month period after
              the successful completion of the initial 40-hour classroom training. The in-service training
              must total a minimum of eight (8) hours each 12-month period beginning with the date of
              certification as a paraprofessional and each 12-month period thereafter. The in-service
              training may be conducted, in part, in the field. Documentation of in-service hours will be
              maintained in the employee’s personnel record and will be available for inspection by
              regulatory agencies.

        A mental health paraprofessional who can provide documentation of training or experience in
        mental health service delivery may be exempt from the 40-hour classroom training. This does
        not exclude the paraprofessional from the requirement of successfully completing an
        examination and skills test.

        All mental health paraprofessionals who provided mental health services for a Medicaid certified
        RSPMI provider on or before October 1, 1989, and since November 1, 1988, will be certified as
        mental health paraprofessionals. These mental health paraprofessionals may be exempt from
        the 40-hour classroom training. However, a written examination of the mental health
        paraprofessional’s knowledge of the 40-hour training course must be successfully completed
        and an evaluation of his or her ability to perform the daily living skills must be successfully
        completed by means of a skills test. A certificate must be awarded to the mental health
        paraprofessional and available for review by the Division of Medical Services staff upon request.

    214.000          Facility Requirements                                                         10-13-03

        The administration of the program shall be responsible for providing physical facilities that are
        structurally sound and meet all applicable federal, state and local regulations for adequacy of
        construction, safety, sanitation and health.

    215.000          Non-Refusal Requirement                                                       10-13-03

        The RSPMI provider may not refuse services to a Medicaid-eligible beneficiary who meets the
        requirements for RSPMI services as outlined in this manual unless, based upon the primary
        mental health diagnosis, the provider does not possess the services or program to adequately
        treat the beneficiary’s mental health needs.

    216.000          Scope                                                                           6-1-05


                                                                                                      Section II-7
Rehabilitative Services for Persons with Mental Illness                                                Section II

        A range of mental health rehabilitative or palliative services is provided by a duly certified RSPMI
        provider to Medicaid-eligible beneficiaries suffering from mental illness, as described in the
        American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV and subsequent
        revisions).
        Rehabilitative Services for Persons with Mental Illness may be covered only when:
        A.    Provided by qualified providers,

        B.    Approved by a physician within 14 calendar days of entering care,

        C.    Provided according to a written treatment plan/plan of care, and

        D.    Provided to outpatients only except as described in Section 252.130.

        E.    In order to be valid, the treatment plan/plan of care must:
              1.     Be prepared according to guidelines developed and stipulated by the organization’s
                     accrediting body and
              2.     Be signed and dated by the physician who certifies medical necessity.
                     If the beneficiary receives care under the treatment plan, the initial treatment
                     plan/plan of care must be approved by the physician within 14 calendar days of the
                     initial receipt of care.
                     The physician’s signature is not valid without the date signed.

    217.000          RSPMI Program Entry                                                            6-1-05

        Prior to providing treatment services, an intake evaluation must be performed for each
        beneficiary being considered for entry into a RSPMI Program. The evaluation is a written
        assessment that evaluates the beneficiary’s mental condition and, based on the beneficiary’s
        diagnosis, determines whether treatment in the RSPMI Program would be appropriate. The
        assessment must be made a part of the beneficiary’s records.
        The intake evaluation must be conducted by a mental health professional qualified by licensure
        and experienced in the diagnosis and treatment of mental illness.

        For each beneficiary served through the RSPMI Program, the treatment team must certify that
        the program is appropriate to meet the beneficiary’s needs. This certification must be
        documented in the beneficiary record within 14 calendar days of the person’s entering continued
        care (first billable service), through treatment team signatures on the treatment plan/plan of care.
        The treatment team must include, at a minimum, a physician and an individual qualified, by
        licensure and experience, in diagnosis and treatment of mental illness. (Both criteria may be
        satisfied by the same individual, if appropriately qualified.)

    217.100          Primary Care Physician (PCP) Referral                                          8-1-05

        A PCP referral is required for individuals under age 21 for RSPMI services except those listed in
        Section 217.111. Verbal referrals from PCP's are acceptable to Medicaid as long as they are
        documented in the beneficiary's chart as described in Section 182.100.

        See Section I of this manual for an explanation of the process to obtain a PCP referral.

                                                           ®
    217.101          Youth Outcome Questionnaire (YOQ )                                             9-1-10

        The Y-OQ® 2.01, the Y-OQ® SR, the Arkansas Indicators and the OQ®-45.2 are instruments for
        measuring service/treatment effectiveness and treatment planning.

        The OQ® instruments are user friendly to both the beneficiaries and to the provider. For the
        beneficiary, they are brief and easy to understand. For the provider, they are easy to administer.

                                                                                                     Section II-8
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        Frequency

        Providers must follow the OQ® Clinician Guide specialized for the State of Arkansas located at
        https://www.oqarkansas.com/oqa. At a minimum, the OQ® instruments must be administered
        within 14 days of entering care, then every 90 days to coincide with Periodic Review of
        Treatment Plans, and at discharge. At a minimum, the Arkansas Indicators must be administered
        every 90 days. Documentation of clinical exceptions to frequencies stated in the OQ® Clinical
        Guide must be included in the clinical record.
        Documentation Requirements
        If the parent or legal guardian for children/adolescents under the age of 16 is not available to
        complete the Y-OQ®2.1 or Arkansas Indicators, the provider must have documentation indicating
        barriers to obtaining the Y-OQ®2.1 and Arkansas Indicators. Documentation must include
        attempts to obtain the Y-OQ®2.1, OQ®-45.2 and Arkansas Indicators at the scheduled frequency.
        If a Y-OQ®2.1 or OQ®-45.2 indicates regression or lack of adequate progress, the provider must
        revise the treatment plan or explain the reason for the continuation of the treatment plan in the
        progress notes.
        Without documentation of the YOQ, providers’ claims are subject to recoupment as explained in
        Section 228.335.

    217.111          Procedure Codes Not Requiring PCP Referral for Beneficiaries                   11-1-10
                     Under Age 21

        Services designated by the following procedure codes and modifiers do not require PCP
        referral:
        A.    90801, HA, U1 – Mental Health Evaluation/Diagnosis

        B.    90885, HA, U2 – Master Treatment Plan

        C.    90887, HA, U2 – Interpretation of Diagnosis

        D.    H2011, HA – Crisis Intervention

        E.    T1023, HA, U1 – Psychiatric Diagnostic Assessment

    217.112          Medicaid Eligible at the Time the Service is Provided                           8-1-05

        A PCP referral is required. The referral is recommended prior to providing service to Medicaid-
        eligible children. However, a PCP is given the option of providing a referral after a service is
        provided. If a PCP chooses to make a referral after a service has been provided, the referral
        must be received by the RSPMI provider no later 45 calendar days after the date of service. The
        PCP has no obligation to give a retroactive referral.
        The RSPMI provider may not file a claim and will not be reimbursed for any services provided
        that require a PCP referral unless the referral is received. If the PCP declines to provide the
        referral retroactive to the date of service, services may be billed beginning the date he/she
        completes the referral, or the date shown on the referral as the approved date. Medicaid will not
        cover the services provided prior to the date approved by the PCP. See Section 182.000.

    217.113          Medicaid Ineligible at the Time the Service is Provided                         8-1-05

        A.    When a child who is not eligible for Medicaid receives an outpatient mental health service,
              an application for Medicaid eligibility may be filed by the child or his or her representative.




                                                                                                       Section II-9
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        B.    If the application for Medicaid coverage is approved, a PCP referral is not required for the
              period prior to the Medicaid authorization date. This period is considered retroactive
              eligibility and does not require a referral.

        C.    A PCP referral is required no later than forty-five calendar days after the authorization
              date. If the PCP referral is not obtained within forty-five calendar days of the Medicaid
              authorization date, reimbursement will begin (if all other requirements are met) for services
              provided upon eligibility authorization and after, the date the PCP referral is received.

              A PCP is given the option of providing a referral after a service is provided. However, the
              PCP has no obligation to give a retroactive referral. The RSPMI provider may not file a
              claim and will not be reimbursed for any services provided that require a PCP referral
              unless the referral has been received. See Section 182.000.

              To verify the authorization date, a provider may call HP Enterprise Services or the local
              DHS office. View or print HP Enterprise Services PAC contact information. View or
              print the DHS office contact information.

    218.000          Master Treatment Plan                                                          10-4-09

        For each beneficiary entering the RSPMI Program, the treatment team must develop an
        individualized master treatment plan. This consists of a written, individualized plan to treat,
        ameliorate, diminish or stabilize or maintain remission of symptoms of mental illness that
        threaten life, or cause pain or suffering, resulting in diminished or impaired functional capacity.
        The master treatment plan goals and objectives must be based on problems identified in the
        intake assessment or in subsequent assessments during the treatment process. The master
        treatment plan must be included in the beneficiary records and contain a written description of
        the treatment objectives for that beneficiary. It also must describe:
        A.    The treatment regimen—the specific medical and remedial services, therapies and
              activities that will be used to meet the treatment objectives;

        B.    A projected schedule for service delivery—this includes the expected frequency and
              duration of each type of planned therapeutic session or encounter;

        C.    The type of personnel that will be furnishing the services and

        D.    A projected schedule for completing reevaluations of the patient’s condition and updating
              the master treatment plan.

        The RSPMI master treatment plan must be completed by a mental health professional and
        approved by a psychiatrist or physician, within 14 calendar days of the individual’s entering care
        (first billable service). Subsequent revisions in the master treatment plan will be approved in
        writing (signed and dated) by the psychiatrist or physician verifying continued medical necessity.

    218.100          Periodic Treatment Plan Review                                                        5-1-08

        The RSPMI treatment plan must be periodically reviewed by the treatment team in order to
        determine the beneficiary’s progress toward the rehabilitative treatment and care objectives, the
        appropriateness of the rehabilitative services provided and the need for the enrolled beneficiary’s
        continued participation in the RSPMI Program. The reviews must be performed on a regular
        basis (at least every 90 calendar days), documented in detail in the enrolled beneficiary’s record,
        kept on file and made available as requested for state and federal purposes. If provided more
        frequently, there must be documentation of significant acuity or change in clinical status requiring
        an update in the beneficiary’s treatment plan. The clock for the 90-day review begins to run on
        the earliest date set forth on the form that contains the treatment plan.

    218.101          Participation of Families and Children in the Periodic Review of the                  7-1-08
                     Treatment Plan for Children Under Age 21

                                                                                                      Section II-10
Rehabilitative Services for Persons with Mental Illness                                               Section II

        The review of the treatment plan must reflect the beneficiary’s, or in the case of a beneficiary
        under the age of 18, the parent’s or guardian’s, assessment of progress toward meeting
        treatment goals or objectives and their level of satisfaction with the treatment services provided.
        Problems, needs, goals, objectives, strengths and supports should be revised based on the
        progress made, barriers encountered, changes in clinical status and any other new information.
        The beneficiary, the parent or the guardian must be provided an opportunity to express
        comments about the treatment plan and a space on the treatment plan form to record these
        comments and their level of satisfaction with the services provided. The review of the plan of
        care must be signed by the MHP who drafted the plan, the physician authorizing and supervising
        the treatment, agency staff members who will provide specific treatment interventions, the
        beneficiary (unless clinically or developmentally contra-indicated) and a parent or legal guardian
        for beneficiaries under the age of 18.
        If the parent or legal guardian for beneficiaries under the age of 18 is not available to provide a
        signature on the review of the treatment plan, the client record must have documentation
        indicating barriers to obtaining that signature within 14 calendar days of the the treatment plan
        review. Documentation, either on the review of treatment plan form or in a progress note must
        include the method of communication with the parent or guardian regarding the parent’s or legal
        guardian’s perception on treatment progress and services provided, revisions needed to the
        treatment plan and involvement of the parent or guardian in ongoing treatment services provided
        for the beneficiary.

    219.000          Covered Services                                                            10-13-03

        The RSPMI services listed below are available to Medicaid-eligible beneficiaries whose primary
        diagnosis is mental illness. When the primary diagnosis is other than mental illness, e.g.,
        substance abuse, RSPMI services are not covered by Arkansas Medicaid.

    219.100          Outpatient Services                                                          10-4-09

        RSPMI outpatient services, based on a plan of care, include a broad range of services to
        Medicaid-eligible beneficiaries. Beneficiaries shall be served with an array of treatment services
        outlined on their individualized master treatment plan in an amount and duration designed to
        meet their medical needs.

    219.110          Daily Limit of Beneficiary Services                                          10-4-09

        Medicaid Beneficiaries will be limited to a maximum of eight hours per 24 hour day of outpatient
        services with the exception of Crisis Intervention, Crisis Stabilization Intervention by Mental
        Health Professional and Crisis Stabilization Intervention by Mental Health Paraprofessional.
        Beneficiaries will be eligible for an extension of the daily maximum amount of services based on
        a medical necessity review by the contracted utilization management entity (See Section
        231.100 for details regarding extension of benefits).

    219.130          Routine Venipuncture for Collection of Specimen                             10-13-03

        A specimen collection may only be provided to patients taking prescribed psychotropic drugs or
        who are involved in drug abuse as verified through the diagnosis procedure.

        This service must be performed by a physician or a licensed nurse under the direction of a
        physician. Arkansas Medicaid policy regarding collection, handling and/or conveyance of
        specimens is as follows:
        A.    Reimbursement is not available for specimen handling fees.

        B.    A specimen collection fee is covered only for:
              1.     Drawing a blood sample through venipuncture (i.e., inserting a needle into a vein to
                     draw the specimen with a syringe or vacutainer) or

                                                                                                   Section II-11
Rehabilitative Services for Persons with Mental Illness                                               Section II

              2.     Collecting a urine sample by catheterization.
        C.    Specimen collection is covered only when the specimen collected is sent to a reference
              laboratory for tests. Reimbursement for collection of specimen is included in the
              reimbursement for lab tests when the practitioner, clinic or facility that collects the
              specimen performs the tests.

    219.140          Telemedicine (Interactive Electronic Transactions) RSPMI Services          10-5-09

        RSPMI telemedicine services are interactive electronic transactions performed ―face-to-face‖ in
        real time, via two-way electronic video and audio data exchange.

        The mental health professional may provide certain treatment services from a remote site to the
        Medicaid-eligible beneficiary age 21 or over who is located in a mental health clinic setting.
        There must be an employee of the clinic in the same room with the beneficiary. Refer to Section
        252.140 for billing instructions.
        The following services may be provided via telemedicine by a mental health professional:
        A.    Mental Health Evaluation/Diagnosis,

        B.    Interpretation of Diagnosis,

        C.    Individual Psychotherapy,

        D.    Marital/Family Psychotherapy – Beneficiary is not present,

        E.    Marital/Family Psychotherapy – Beneficiary is present,

        F.    Psychiatric Diagnostic Assessment,

        G.    Crisis Intervention,

        H.    Crisis Stabilization Intervention, Mental Health Professional,

        I.    Pharmacologic Management by Physician,

        J.    Collateral Intervention, Mental Health Professional; and

        K.    Intervention, Mental Health Professional.

    219.141          Services Available to Residents of Long Term Care Facilities               10-5-09

        The following RSPMI services may be provided to residents of nursing homes and ICF/MR
        facilities who are Medicaid eligible when the services are prescribed according to policy
        guidelines detailed in this manual:
        A.    Mental Health Evaluation/Diagnosis,

        B.    Psychological Evaluation,

        C.    Pharmacologic Management by Physician,

        D.    Master Treatment Plan,

        E.    Periodic Review of Master Treatment Plan,

        F.    Interpretation of Diagnosis,

        G.    Individual Psychotherapy,

        H.    Crisis Intervention.

                                                                                                   Section II-12
Rehabilitative Services for Persons with Mental Illness                                                   Section II

        Services provided to nursing home and ICF/MR residents may be provided on- or off-site from
        the RSPMI provider if allowable per the service definition. Some services may be provided in the
        long-term care (LTC) facility, if necessary.

    220.000          Inpatient Hospital Services                                                    10-13-03

        ―Inpatient‖ means a patient who has been admitted to a medical institution on recommendation
        of a licensed practitioner authorized to admit patients; and who is receiving room, board and
        professional services in the institution on a continuous 24-hour-a-day basis; or who is expected
        by the institution to receive room, board and professional services for 24 hours or longer.

    220.100          Hospital Visits                                                                10-13-03

        Inpatient hospital visits are Medicaid covered only for board certified or board eligible
        psychiatrists employed by the RSPMI provider. Each attending physician is limited to billing one
        day of care for an inpatient hospital Medicaid covered day, regardless of the number of hospital
        visits made by the physician.

        A ―Medicaid covered day‖ is defined as a day for which the patient is Medicaid eligible, the
        patient’s inpatient benefit limit has not been exhausted, the patient’s inpatient stay is medically
        necessary, the day is not part of a hospital stay for a non-payable procedure or non-authorized
        procedure and the claim is filed on time. (See Section III of this manual for information regarding
        ―Timely Filing.‖)

    220.200          Inpatient Hospital Services Benefit Limit                                      10-13-03

        There is no inpatient benefit limit for Medicaid-eligible individuals under age 21. The benefit limit
        for general and rehabilitative hospital inpatient services is 24 paid inpatient days per state fiscal
        year (July 1 through June 30) for Medicaid beneficiaries aged 21 and older. Extension of this
        benefit is not available.

    221.000          Medicaid Utilization Management Program (MUMP)                                 10-13-03

        The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in
        inpatient, general and rehabilitative hospitals, both in state and out of state. The MUMP does
        not apply to lengths of stay in psychiatric facilities.
        Lengths-of-stay determinations are made by the Quality Improvement Organization (QIO),
        Arkansas Foundation for Medical Care, Inc., (AFMC) under contract to the Arkansas Medicaid
        Program.

    221.100          MUMP Applicability                                                             10-13-03

        A.    Medicaid covers up to four (4) days of inpatient service with no certification requirement,
              except in the case of a transfer (see subpart B, below). If a patient is not discharged
              before or during the fifth day of hospitalization, additional days are covered only if certified
              by AFMC.

        B.    When a patient is transferred from one hospital to another, the stay in the receiving
              hospital must be certified from the first day.

    221.110          MUMP Exemptions                                                                10-13-03

        A.    Individuals in all Medicaid eligibility categories and all age groups, except beneficiaries
              under age one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at
              the time of admission are exempt from the MUMP policy for dates of service before their
              first birthday.


                                                                                                       Section II-13
Rehabilitative Services for Persons with Mental Illness                                                     Section II

        B.    MUMP policy does not apply to inpatient stays for bone marrow, liver, heart, lung, skin and
              pancreas/kidney transplant procedures.

    221.200          MUMP Procedures                                                                  10-13-03

        MUMP procedures are detailed in the following sections of this manual:
        A.    Direct (non-transfer) admissions – Section 221.210

        B.    Transfer admissions – Section 221.220

        C.    Certifications of inpatient stays involving retroactive eligibility – Section 221.230

        D.    Inpatients with third party or Medicare coverage – Section 221.240

        E.    Reconsideration reviews of denied extensions – Section 221.250

    221.210          Direct Admissions                                                                10-13-03

        A.    When the attending physician determines the patient should not be discharged by the fifth
              day of hospitalization, a hospital medical staff member may contact AFMC and request an
              extension of inpatient days. View or print AFMC contact information. The following
              information is required:
              1.     Patient name and address (including ZIP code),
              2.     Patient birth date,
              3.     Patient Medicaid number,
              4.     Admission date,
              5.     Hospital name,
              6.     Hospital Medicaid provider number,
              7.     Attending physician Medicaid provider number,
              8.     Principal diagnosis and other diagnosis influencing this stay,
              9.     Surgical procedures performed or planned,
              10.    The number of days being requested for continued inpatient stay and
              11.    All available medical information justifying or supporting the necessity of continued
                     stay in the hospital.
        B.    Calls for extension of days may be made at any time during the inpatient stay (except in
              the case of a transfer from another hospital–refer to Section 221.220).
              1.     Providers initiating their request after the fourth day must accept the financial liability
                     should the stay not meet necessary medical criteria for inpatient services.
              2.     When the provider delays calling for extension verification and the services are
                     denied based on medical necessity, the beneficiary may not be held liable.
              3.     If the fifth day of admission falls on a Saturday, Sunday or holiday, it is
                     recommended that the hospital provider call for an extension prior to the fifth day, if
                     the physician has recommended a continued stay.
        C.    When a Medicaid beneficiary reaches age one (1) during an inpatient stay, the days from
              the admission date through the day before the patient’s birthday are exempt from the
              MUMP policy. MUMP policy becomes effective on the one-year birthday. The patient’s
              birthday is the first day of the four days not requiring MUMP certification. If the stay
              continues beyond the fourth day following the patient’s first birthday, hospital staff must
              apply for MUMP certification for the additional days.

                                                                                                         Section II-14
Rehabilitative Services for Persons with Mental Illness                                                        Section II

        D.    AFMC utilizes Medicaid guidelines and the medical judgment of its professional staff to
              determine the number of days to allow.

        E.    AFMC assigns an authorization number to an approved extension request and sends
              written notification to the hospital.

        F.    Additional extensions may be requested as needed.

        G.    The certification process under the MUMP is separate from prior authorization
              requirements. Prior authorization for medical procedures thus restricted must be obtained
              by the appropriate providers. Hospital stays for restricted procedures may be disallowed if
              required prior authorizations are not obtained.

        H.    Claims submitted without calling for an extension request will result in automatic
              denials of any days billed beyond the fourth day. There will be no exceptions
              granted except for claims reflecting third party liability.

    221.220          Transfer Admissions                                                              10-13-03

        If a patient is transferred from one hospital to another, the receiving facility must contact AFMC
        within 24 hours of admitting the patient to certify the inpatient stay. If admission falls on a
        weekend or holiday, the provider may contact AFMC on the first working day following the
        weekend or holiday.

    221.230          Retroactive Eligibility                                                          10-13-03

        A.    If eligibility is determined while the patient is still an inpatient, the hospital may call to
              request post-certification of inpatient days beyond the first four (4) (or all days if the
              admission was by transfer) and a concurrent certification of additional days, if needed.

        B.    If eligibility is determined after discharge, the hospital may call AFMC for post-certification
              of inpatient days beyond the first four (4) (or all days if the admission was by transfer). If
              certification sought is for a stay longer than 30 days, the provider must submit the entire
              medical record to AFMC for review.

    221.240          Third Party and Medicare Primary Claims                                          10-13-03

        A.    If a provider has not requested MUMP certification of inpatient days because there is
              apparent coverage by insurance or Medicare Part A, but the other payer has denied the
              claim for non-covered service, lost eligibility, benefits exhausted, etc., post-certification
              required by the MUMP may be obtained as follows:
              1.     Send a copy of the third party payer’s denial notice to AFMC, attention Pre-
                     Certification Supervisor. View or print AFMC contact information.
              2.     Include a written request for post-certification.
              3.     Include complete provider contact information: full name and title, telephone number
                     and extension.
              4.     An AFMC coordinator will call the provider contact for the certification information.
        B.    If a third party insurer pays the provider for an approved number of days, Medicaid will not
              grant an extension for days beyond the number of days approved by the private insurer.

    221.250          Request for Reconsideration                                                      10-13-03

        Reconsideration reviews of denied extensions may be expedited by faxing the medical record to
        AFMC. AFMC will advise the hospital of its decision by the next working day. View or print
        AFMC contact information.

                                                                                                         Section II-15
Rehabilitative Services for Persons with Mental Illness                                                  Section II


    221.260          Post-Payment Review                                                           10-13-03

        A post payment review of a 30% random sample is conducted on all admissions, including
        inpatient stays of four days or less, to ensure that medical necessity for the services is
        substantiated.

    222.000          Approved Service Locations                                                    10-13-03

        Rehabilitative Services for Persons with Mental Illness (RSPMI) are covered by Medicaid only in
        the outpatient setting, except for inpatient hospital visits by board-certified psychiatrists.

        The services and procedure codes available for billing for RSPMI providers are listed in Section
        250.000 of this manual.

    223.000          Exclusions                                                                     10-4-09

        Services not covered under the RSPMI Program include, but are not limited to:
        A.    Room and board residential costs;

        B.    Educational services;

        C.    Telephone contacts with patient or collateral;

        D.    Transportation services, including time spent transporting a beneficiary for services
              (reimbursement for other RSPMI services is not allowed for the period of time the
              Medicaid beneficiary is in transport);

        E.    Services to individuals with developmental disabilities that are non-psychiatric in nature,
              except for testing purposes;

        F.    RSPMI services which are found not to be medically necessary and

        G.    RSPMI services provided to nursing home and ICF/MR residents other than those
              specified in Section 252.150.

    224.000          Physician’s Role

    224.100          Physician’s Role for Adults Age 21 and Over                                     7-1-08

        RSPMI providers are required to have a board certified or board eligible psychiatrist who
        provides appropriate supervision and oversight for all medical and treatment services provided
        by the agency. A physician will supervise and coordinate all psychiatric and medical functions as
        indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in
        Arkansas, preferably one specializing in psychiatry. If medical responsibility is not vested in a
        psychiatrist, then psychiatric consultation must be available on a regular basis. For RSPMI
        enrolled adults, age 21 and over, medical supervision responsibility shall include, but is not
        limited to, the following:
        A.    For any individuals certified as being Seriously Mentally Ill (SMI) , the physician will see
              and evaluate the individual the earlier of 45 days of the individual’s entering care or 45
              days from the effective date of certification of serious mental illness. This evaluation is not
              required if the beneficiary discontinues services prior to calendar day 45. The SMI/SED
              beneficiary must be re-evaluated directly by a physician within one year after the date of
              the examination and at least every year thereafter.

        B.    For individuals not certified as having a Serious Mental Illness or Serious Emotional
              Disturbance, the physician may determine through review of beneficiary records and
              consultation with the treatment staff that it is not medically necessary to directly see the
                                                                                                      Section II-16
Rehabilitative Services for Persons with Mental Illness                                                 Section II

              enrolled beneficiary. By calendar day 45 after entering care, the physician must document
              in the beneficiary’s record that it is not medically necessary to see the beneficiary. If the
              beneficiary continues to be in care for more than six months after program entry, the
              psychiatrist/physician shall see and evaluate the individual directly by the end of six
              months, initially, then at least every year, thereafter.

        C.    The physician will review and approve the enrolled beneficiary’s RSPMI treatment plan and
              document approval in the enrolled beneficiary’s record. If the treatment plan is revised
              prior to each 90 day interval, the physician must approve the changes within 14 calendar
              days, as indicated by a dated signature on the revised plan.

        D.    Approval of all updated or revised treatment plans must be documented by the physician’s
              dated signature on the revised document. The new 90-day period begins on the date the
              revised treatment plan is completed.

    224.200          Physician’s Role for Children Under Age 21                                      7-1-08

        RSPMI providers are required to have a board certified or board eligible psychiatrist who
        provides supervision and oversight for all medical and treatment services provided by the
        agency. A physician will supervise and coordinate all psychiatric and medical functions as
        indicated in treatment plans. Medical responsibility shall be vested in a physician licensed in
        Arkansas, preferably one specializing in psychiatry. If medical responsibility is not vested in a
        psychiatrist, then psychiatric consultation must be available on a regular basis. For RSPMI
        enrolled children, under age 21, medical supervision responsibility shall include, but is not limited
        to, the following:

        A. For any individuals under age 18, certified as being Seriously Emotionally Disturbed (SED)
           or individuals age 18 through age 20 certified as Seriously Mentally Ill (SMI) , the physician
           will conduct a psychiatric Diagnostic Assessment of the individual the earlier of 45 days of
           the individual’s entering care or 45 days from the effective date of certification of serious
           mental illness/serious emotional disturbance. This evaluation is not required if the
           beneficiary discontinues services prior to calendar day 45. The SMI/SED beneficiary must be
           evaluated again directly by the physician within one year after the date of the examination
           and at least every year thereafter.

        B. For individuals not certified as having a Serious Mental Illness or Serious Emotional
           Disturbance, the psychiatrist or physician may determine through review of beneficiary
           records and consultation with the treatment staff that it is not medically necessary to directly
           assess and interview the enrolled beneficiary. By calendar day 45 after entering care, the
           physician must document in the beneficiary’s record that it is not medically necessary to
           provide the beneficiary a physician assessment. If the beneficiary continues to be in care for
           more than six months after program entry, the psychiatrist/physician must conduct a
           Psychiatric Diagnostic Assessment of the individual directly by the end of six months, initially,
           then at least every year, thereafter.
        C. The physician will review and approve the enrolled beneficiary’s RSPMI treatment plan and
           document the approval in the enrolled beneficiary’s record. If the treatment plan is revised
           prior to each 90 day interval, the physician must approve the changes within 14 calendar
           days, as indicated by a dated signature on the revised plan.

        D. Approval of all updated or revised treatment plans must be documented by the physician’s
           dated signature on the revised document. The new 90-day period begins on the date the
           revised treatment plan is completed.

    224.201          Psychiatric Diagnostic Assessment                                               5-1-08

        The purpose of this service is to determine the existence, type, nature, and most appropriate
        treatment of a mental illness or emotional disorder as defined by DSM-IV or ICD-9. This face to
        face psychodiagnostic process must be conducted by an Arkansas licensed physician,

                                                                                                     Section II-17
Rehabilitative Services for Persons with Mental Illness                                               Section II

        preferably one with specialized training and experience in psychiatry (child and adolescent
        psychiatry for beneficiaries under age 18). The process must include:
        A.    An interview with the beneficiary, which covers the areas outlined below. The psychiatric
              diagnostic assessment may build on information obtained through other assessments
              reviewed by the physician and verified through the physician’s interview. The interview
              should obtain or verify:
              1.     The beneficiary’s understanding of the factors leading to the referral,
              2.     The presenting problem,
              3.     Relevant life circumstances and psychological factors,
              4.     Current symptoms and functional impairments,
              5.     History of problems,
              6.     Symptoms and functional impairments,
              7.     Treatment history,
              8.     Response to prior treatment interventions and
              9.     Medical history (and examination as indicated).
        B.    The assessment must include:
              1.     A mental status evaluation (a developmental mental status evaluation for
                     beneficiaries under age 18) and
              2.     A complete multi-axial diagnosis.
        C.    For beneficiaries under the age of 18, the psychiatric diagnostic assessment must also
              include an interview of a parent (preferably both), the guardian (including the responsible
              DCFS caseworker) and/or the primary caretaker (including foster parents) in order to:
              1.     Clarify the reason for referral,
              2.     Clarify the nature of the current symptoms and functional impairments and
              3.     To obtain a detailed medical, family and developmental history.

        The diagnostic assessment must contain sufficient detailed information to substantiate all
        diagnoses specified in the assessment and treatment plan, all functional impairments listed on
        SED or SMI certifications and all problems or needs to be addressed on the treatment plan. The
        Psychiatric Diagnostic Assessment must be updated every 12 months at a minimum.

    225.000          Diagnosis and Clinical Impression                                           10-13-03

        Diagnosis and clinical impression is required in the terminology of the ICD-9-CM.

    226.000          Documentation/Record Keeping Requirements

    226.100          Reserved                                                                     11-1-09


    226.200          Documentation                                                                10-4-09

        The RSPMI provider must develop and maintain sufficient written documentation to support each
        medical or remedial therapy, service, activity or session for which Medicaid reimbursement is
        sought. This documentation, at a minimum, must consist of:
        A.    Must be individualized to the beneficiary and specific to the services provided, duplicated
              notes are not allowed.


                                                                                                   Section II-18
Rehabilitative Services for Persons with Mental Illness                                               Section II

        B.    The date and actual time the services were provided (Time frames may not overlap
              between services. All services must be outside the time frame of other services.),

        C.    Name and credentials of the person, who provided the services,

        D.    The setting in which the services were provided. For all settings other than the provider’s
              enrolled sites, the name and physical address of the place of service must be included,

        E.    The relationship of the services to the treatment regimen described in the plan of care and

        F.    Updates describing the patient’s progress and

        G.    For services that require contact with anyone other than the beneficiary, evidence of
              conformance with HIPAA regulations, including presence in documentation of Specific
              Authorizations, is required.

        Documentation must be legible and concise. The name and title of the person providing the
        service must reflect the appropriate professional level in accordance with the staffing
        requirements found in Section 213.000.
        For Therapeutic Day/Acute Day and Rehabilitative Day Services, progress notes must be
        entered daily. Daily notes may be brief; however, they must meet requirement of item F above.
        Providers may enter weekly progress notes that summarize the beneficiary’s progress in
        relationship to the plan of care.

        All documentation must be available to representatives of the Division of Medical Services at the
        time of an audit by the Medicaid Program Integrity Unit. All documentation must be available at
        the provider’s place of business. No more than thirty (30) days will be allowed after the date on
        the recoupment notice in which additional documentation will be accepted. Additional
        documentation will not be accepted after the 30-day period.

    227.000          Medical Necessity                                                            10-4-09

        All RSPMI services must be medically necessary.

    227.001          Prescription for RSPMI Services                                              10-4-09

        Medicaid will not cover any RSPMI service without a current prescription signed by a psychiatrist
        or physician. Prescriptions shall be based on consideration of the RSPMI Assessment and
        proposed master treatment plan and an evaluation of the enrolled beneficiary (directly or through
        review of the medical records and consultation with the treatment staff). The prescription of the
        services will be documented by the psychiatrist’s or physician’s written approval of the RSPMI
        master treatment plan. Subsequent revisions of the patient’s RSPMI master treatment plan will
        also be documented by the psychiatrist’s or physician’s written approval in the enrolled
        beneficiary’s medical record. Approval of all updates or revisions to the Master treatment plan
        must be documented within 14 calendar days by the physician’s dated signature on the revised
        document.

    227.100          Prescription for Speech Therapy                                              10-4-09

        Speech therapy services are available to Medicaid-eligible beneficiaries. Providers of speech
        therapy services are required to have a physician prescription for services in each patient’s
        record.
        A written prescription is required for speech therapy services, signed and dated by the PCP or
        the attending physician. Form DMS-640 is required for the prescription. The form must be in the
        patient’s record. View or print form DMS-640.
        A.    The beneficiary’s PCP or attending physician must sign the prescription.


                                                                                                   Section II-19
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        B.    A prescription for speech therapy services is valid for 1 year unless the prescribing
              physician specifies a shorter period of time.

    227.110          Procedures for Obtaining Extension of Benefits for Speech Therapy             11-1-05

        Requests for extension of benefits for speech therapy services for beneficiaries under age 21
        must be mailed to the Arkansas Foundation for Medical Care, Inc. (AFMC). View or print
        Arkansas Foundation for Medical Care, Inc., contact information. A request for extension of
        benefits must meet the medical necessity requirement, and adequate documentation must be
        provided to support this request.
        A.    Requests for extension of benefits are considered only after a claim is denied because the
              patient’s benefit limits are exhausted.

        B.    The request for extension of benefits must be received by AFMC within 90 calendar days
              of the date of the benefits-exhausted denial.
              1.     Submit with the request a copy of the Medical Assistance Remittance and Status
                     Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
              2.     AFMC will not accept extension of benefits requests sent via electronic facsimile
                     (FAX).
        C.    Form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory, and
              X-Ray Services, must be utilized for requests for extension of benefits for therapy services.
              View or print form DMS-671. Consideration of requests for extension of benefits requires
              correct completion of all fields on this form. The instructions for completion of this form are
              located on the back of the form. The provider’s signature (with his or her credentials) and
              the date of the request are required on the form. Stamped or electronic signatures are
              accepted. All applicable records that support the medical necessity of the extended
              benefits request should be attached.

              AFMC will approve or deny an extension of benefits request, or request additional
              information, within 30 calendar days of their receiving the request. AFMC reviewers will
              simultaneously advise the provider and the beneficiary when a request is denied.

    227.111          Reconsideration of Extension of Benefits Denial                               11-1-05

        Any reconsideration request for denial of extension of benefits must be received at AFMC within
        thirty (30) days from the next business day following the postmark date on the envelope
        containing this denial letter. When requesting reconsideration of a denial, the following
        information is required:
        A.    Return a copy of the current NOTICE OF ACTION denial letter with re-submissions.

        B.    Return all previously submitted documentation as well as additional information for
              reconsideration.

        Only one reconsideration is allowed. Any reconsideration request that does not include the
        required documentation will be automatically denied.
        AFMC reserves the right to request further clinical documentation as deemed necessary to
        complete the medical review.

    227.112          Appealing an Adverse Action                                                   11-1-05

        When the state Medicaid agency or its designee denies a benefit extension request, the
        beneficiary and/or the provider may appeal the denial and request a fair hearing.



                                                                                                      Section II-20
Rehabilitative Services for Persons with Mental Illness                                                     Section II

        An appeal request must be in writing and must be received by the Appeals and Hearings Section
        of the Department of Human Services (DHS) within thirty (30) days from the next business day
        following the postmark date on the envelope containing the denial letter. View or print the
        Department of Human Services, Appeals and Hearings Section contact information.

    228.000          Provider Reviews                                                                11-1-04

        The Utilization Review Section of the Arkansas Division of Medical Services has the
        responsibility for assuring quality medical care for its beneficiaries, along with protecting the
        integrity of both state and federal funds supporting the Medical Assistance Program.

    228.100          Reserved                                                                        11-1-09


    228.200          Reserved                                                                        11-1-09


    228.300          Record Reviews                                                                   7-1-10

        The Division of Medical Services (DMS) of Arkansas Department of Human Services (DHS) has
        contracted with ValueOptions to perform on-site inspections of care (IOC) and retrospective
        reviews of outpatient mental health services provided by RSPMI providers. View or print
        ValueOptions contact information. The reviews are conducted by licensed mental health
        professionals and are based on applicable federal and state standards.

    228.310          On-Site Inspections of Care (IOC)

    228.311          Purpose of the Review                                                           11-1-04

        The on-site inspections of care of RSPMI providers are intended to:
        A.    Promote RSPMI services being provided in compliance with federal and state standards;

        B.    Identify and clearly define areas of deficiency where the provision of services is not in
              compliance with federal and state standards;

        C.    Require provider facilities to develop and implement appropriate corrective action plans to
              remediate all deficiencies identified;

        D.    Provide accountability that corrective action plans are implemented; and

        E.    Determine the effectiveness of corrective action plans implemented.

    228.312          Provider Notification of IOC                                                    11-1-04

        The provider will be notified no more than 48 hours before the scheduled arrival of the inspection
        team. It is the responsibility of the provider to provide a reasonably comfortable place for the
        team to work. When possible, this location will provide reasonable access to the patient care
        areas and the medical records.

    228.313          Information Available Upon Arrival of the IOC Team                              11-1-04

        The provider will make the following available to the IOC Team upon arrival at the site:
        A.    Medical records of Arkansas Medicaid beneficiaries who are identified by the reviewer.

        B.    One or more knowledgeable administrative staff member(s) to assist the team;

        C.    The opportunity to assess direct patient care which does not disrupt or distract from the
              actual provision of care;


                                                                                                      Section II-21
Rehabilitative Services for Persons with Mental Illness                                                   Section II

        D.    Staff personnel records, complete with hire dates, dates of credentialing and copies of
              current licenses, credentials, criminal background checks, etc.;

              And, if identified as necessary to clarify specific chart audit questions:

        E.    Written policies, procedures and committee minutes.

        F.    Data collected for Clinical Administration, Clinical Services, Quality Assurance, Quality
              improvement, Utilization Review and Credentialing;

        G.    Program descriptions, manuals, schedules, staffing plans and evaluation studies.

    228.314          Cases Chosen for Review                                                      11-1-04

        The cases are chosen by a case selection procedure that combines random sampling and cases
        identified as ―high utilization‖ and ―outliers.‖
        A.    High Utilizers are defined as beneficiaries who meet pre-defined levels of mental health
              service utilization within an identified period of time.

        B.    Outliers shall be defined as any providers or beneficiaries whose provision of services or
              service utilization meets pre-defined criteria of variance from the norm.

        C.    Cases chosen for review for On-Site Inspections of Care (IOC) are subject to the purpose,
              policies, and procedures specified in Sections 228.331 (Purpose of the Review), 228.333
              (Review Report), 228.334 (Reconsideration), and 228.335 (Recoupments).

        The review period will be specified in the provider notification letter. The list of cases to be
        reviewed will be given to the provider upon arrival or chosen by the IOC Team from a list for that
        location with a request for certain components of the records. The information requested
        includes:
              1.     All required assessments, including SED/SMI Certifications where applicable
              2.     Treatment plans (plan of care) and PoC reviews
              3.     Progress notes, including physician notes
              4.     Physician orders and lab results
              5.     Copies of records. The reviewer may request a copy of any record reviewed.

    228.315          Program Activity Observation                                                 11-1-04

        The reviewer will observe at least one program activity.

    228.316          Beneficiary Interviews                                                       11-1-04

        The provider is required to arrange interviews of Medicaid beneficiaries as requested by the
        reviewer, preferably from the beneficiaries whose records are being reviewed. If the
        beneficiaries whose records are being reviewed are not available, interviews will be conducted
        with beneficiaries on-site whose records are not scheduled for review and the records for those
        beneficiaries will be added to the review.

    228.317          Exit Conference                                                              11-1-04

        The Inspection of Care Team will conduct an exit conference summarizing their findings and
        recommendations. Providers are free to involve staff in the exit conference.

    228.318          Written Reports                                                              11-1-04



                                                                                                    Section II-22
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        A written report of the inspection team’s conclusions will be forwarded to the facility and to the
        Field Audit Unit of the Division of Medical Services within 14 calendar days of the last day of
        inspection. The written report will clearly identify any area of deficiency that requires submission
        of a corrective action plan.

    228.319          Corrective Action Plans                                                        11-1-04

        The facility is required to submit a Corrective Action Plan designed to rectify any area of
        deficiency noted in the written report of the inspection of care.. The Corrective Action Plan must
        be submitted to the contracted utilization review agency within 30 calendar days of the date of
        the written report. The contractor will review the Corrective Action Plan and forward it, along with
        recommendations, to the Field Audit Unit of the Division of Medical Services.

    228.320          Other Actions                                                                  11-1-04

        Other actions that may be taken as part of the inspection of care include, but are not limited to:
        A.    Decertification of any beneficiary determined to no longer meet medical necessity criteria
              for outpatient mental health services.

        B.    Follow-up inspections of care may be recommended by the contracted utilization review
              agency and required by Division of Medical Services to verify the implementation and
              effectiveness of corrective actions. Follow-up inspections may be focused only on the
              issues addressed by the corrective action plans or may be a complete re-inspection of
              care, at the sole discretion of the Division of Medical Services.

        C.    Review by Field Audit Unit of the Division of Medical Services.

    228.330          Retrospective Reviews                                                           7-1-10

        The Division of Medical Services (DMS) of Arkansas Department of Human Services has
        contracted with ValueOptions to perform retrospective (post payment) reviews of outpatient
        mental health services provided by RSPMI providers. View or print ValueOptions contact
        information. The reviews are conducted by licensed mental health professionals and are based
        on applicable federal and state standards.

    228.331          Purpose of the Review                                                          11-1-04

        The purpose of the review is to evaluate the medical necessity of services provided to Medicaid
        beneficiaries of all ages. Reviewers will examine the medical record for technical compliance
        with state and federal regulations. Reviewers will also evaluate the clinical documentation to
        determine if it is sufficient to support the services billed during the requested period of authorized
        services.

    228.332          Cases Chosen for Review                                                         7-1-10

        The notification of retrospective review sent to the provider will contain a list of specific cases
        that must be submitted to the review team. The cases are chosen by a case selection procedure
        that combines random sampling and cases identified as ―high utilization‖ and ―outliers.‖
        A.    High Utilizers are defined as beneficiaries who meet pre-defined levels of mental health
              service utilization within an identified period of time.

        B.    Outliers shall be defined as any providers or beneficiaries whose provision of services or
              service utilization meets pre-defined criteria of variance from the norm.

        The review period will be specified in the provider notification letter. The list of cases to be
        reviewed will be included in the letter with a request for certain components of the records. The
        information requested includes:

                                                                                                      Section II-23
Rehabilitative Services for Persons with Mental Illness                                                  Section II

              1.     All required assessments, including SED/SMI Certifications where applicable
              2.     Treatment plans (plan of care) and PoC reviews
              3.     Progress notes, including physician notes
              4.     Physician orders and lab results

        At the discretion of the contractor, the retrospective review may also include:
              5.     Agency policy, procedure and program description related to the content of RSPMI
                     services, including daily schedules and descriptions of service content
                     and
              6.     Credentials of staff providing services

        All records must be mailed to the contractor. View or print ValueOptions contact information.
        Send records to the attention of ―Retrospective Review Audits.‖ Records must not be faxed.

        The contractor has the right to request other parts of the health record or the entire
        record if needed.

    228.333          Review Report                                                                   11-1-04

        The contractor will complete a written report of the audit findings and will deliver the report to the
        facility and to the Division of Medical Services. If the facility does not request reconsideration of
        the audit report within 30 calendar days of the date on the report, the results of the audit report
        will be final. The contractor will mail the report the same date as that on the report.

    228.334          Reconsideration                                                                 11-1-04

        If the audit report is unfavorable, the provider has the right to request reconsideration by the
        contractor within 30 calendar days from the date on the report. The provider may furnish the
        contractor additional documents from the medical record (if additional information is available) or
        may present a written explanation of why the provider believes any particular audit finding is in
        error. Following the receipt of the written request for reconsideration, the contractor will review
        the findings in question. A written response to the request for reconsideration will be forwarded
        to the facility and to the Division of Medical Services.

        The decision of the contractor, upon reconsideration, is final.

    228.335          Recoupments                                                                     11-1-04

        The final report complete with an analysis of payments made for services the contractor
        determines were not medically necessary will be sent to DMS. The provider will be notified by
        DMS of the amount to be recouped by Medicaid and the methods available for repayment.

    228.400          Retrospective Review of Speech Therapy Services for Individuals                 11-1-05
                     Under Age 21

        Retrospective review of speech therapy services is required for beneficiaries under age 21. The
        purpose of retrospective review is promotion of effective, efficient and economical delivery of
        health care services.

        The Quality Improvement Organization (QIO), Arkansas Foundation for Medical Care, Inc.
        (AFMC), under contract to the Arkansas Medicaid Program, performs retrospective reviews by
        reviewing medical records to determine if services delivered and reimbursed by Medicaid meet
        medical necessity requirements. View or print Arkansas Foundation for Medical Care, Inc.,
        contact information.



                                                                                                      Section II-24
Rehabilitative Services for Persons with Mental Illness                                                 Section II

        Specific guidelines have been developed for speech therapy retrospective reviews. These
        guidelines may be found in the following policy sections.

    228.410          Speech-Language Therapy Guidelines for Retrospective Review                   11-1-10

        A.    Medical Necessity

              Speech-language therapy services must be medically necessary for the treatment of the
              individual’s illness or injury. A diagnosis alone is not sufficient documentation to support
              the medical necessity of therapy. To be considered medically necessary, the following
              conditions must be met:
              1.     The services must be considered under accepted standards of practice to be a
                     specific and effective treatment for the patient’s condition.
              2.     The services must be of such a level of complexity or the patient’s condition must be
                     such that the services required can be safely and effectively performed only by or
                     under the supervision of a qualified speech and language pathologist.
              3.     There must be a reasonable expectation that therapy will result in meaningful
                     improvement or a reasonable expectation that therapy will prevent a worsening of the
                     condition. (See the medical necessity definition in the Glossary of this manual.)
        B.    Types of Communication Disorders
              1.     Language Disorders — Impaired comprehension and/or use of spoken, written
                     and/or other symbol systems. This disorder may involve the following components:
                     forms of language (phonology, morphology, syntax), content and meaning of
                     language (semantics, prosody), function of language (pragmatics) and/or the
                     perception/processing of language. Language disorders may involve one, all or a
                     combination of the above components.
              2.     Speech Production Disorders — Impairment of the articulation of speech sounds,
                     voice and/or fluency. Speech Production disorders may involve one, all or
                     combination of these components of the speech production system.
                     An articulation disorder may manifest as an individual sound deficiency, i.e.,
                     traditional articulation disorder, incomplete or deviant use of the phonological system,
                     i.e. phonological disorder, or poor coordination of the oral-motor mechanism for
                     purposes of speech production, i.e. verbal and/or oral apraxia, dysarthria.
              3.     Oral Motor/Swallowing/Feeding Disorders — Impairment of the muscles, structures
                     and/or functions of the mouth (physiological or sensory-based) involved with the
                     entire act of deglutition from placement and manipulation of food in the mouth
                     through the oral and pharyngeal phases of the swallow. These disorders may or
                     may not result in deficits to speech production.
        C.    Evaluation and Report Components
              1.     STANDARDIZED SCORING KEY:
                     Mild: Scores between 84-78; -1.0 standard deviation
                     Moderate: Scores between 77-71; -1.5 standard deviations
                     Severe: Scores between 70-64; -2.0 standard deviations
                     Profound: Scores of 63 or lower; -2.0+ standard deviations
              2.     LANGUAGE: To establish medical necessity, results from a comprehensive
                     assessment in the suspected area of deficit must be reported. (Refer to Section
                     228.410, part D, paragraphs 9-12 for required frequency of re-evaluations.) A
                     comprehensive assessment for Language disorder must include:
                     a.    Date of evaluation.

                                                                                                     Section II-25
Rehabilitative Services for Persons with Mental Illness                                                   Section II

                     b.    Child’s name and date of birth.
                     c.    Diagnosis specific to therapy.
                     d.    Background information including pertinent medical history; and, if the child is
                           12 months of age or younger, gestational age. The child should be tested in
                           the child’s dominant language; if not, an explanation must be provided in the
                           evaluation.
                           NOTE: To calculate a child’s gestational age, subtract the number of
                                 weeks born before 40 weeks of gestation from the chronological
                                 age. Therefore, a 7-month-old, former 28 week gestational age
                                 infant has a corrected age of 4 months according to the following
                                 equation:
                                 7 months - [(40 weeks) - 28 weeks) / 4 weeks]

                                     7 months - [(12) / 4 weeks]
                                     7 months - [3]

                                     4 months
                     e.    Results from an assessment specific to the suspected type of language
                           disorder, including all relevant scores, quotients and/or indexes, if applicable.
                           A comprehensive measure of language must be included for initial evaluations.
                           Use of one-word vocabulary tests alone will not be accepted. (Review Section
                           228.414 — Accepted Tests for Speech-Language Therapy.)
                     f.    If applicable, test results should be adjusted for prematurity (less than 37
                           weeks gestation) if the child is 12 months of age or younger, and this should be
                           noted in the evaluation.
                     g.    Oral-peripheral speech mechanism examination, which includes a description
                           of the structure and function of the orofacial structures.
                     h.    Formal or informal assessment of hearing, articulation, voice and fluency skills.
                     i.    An interpretation of the results of the evaluation including recommendations for
                           frequency and intensity of treatment.
                     j.    A description of functional strengths and limitations, a suggested treatment
                           plan and potential goals to address each identified problem.
                     k.    Signature and credentials of the therapist performing the evaluation.
              3.     SPEECH PRODUCTION (Articulation, Phonological, Apraxia): To establish medical
                     necessity, results from a comprehensive assessment in the suspected area of deficit
                     must be reported. (Refer to Section 228.410, part D, paragraphs 9-12 for required
                     frequency of re-evaluations.) A comprehensive assessment for Speech Production
                     (Articulation, Phonological, Apraxia) disorder must include:
                     a.    Date of evaluation.
                     b.    Child’s name and date of birth.
                     c.    Diagnosis specific to therapy.
                     d.    Background information including pertinent medical history; and, if the child is
                           12 months of age or younger, gestational age. The child should be tested in
                           the child’s dominant language; if not, an explanation must be provided in the
                           evaluation.
                           NOTE: To calculate a child’s gestational age, subtract the number of
                                 weeks born before 40 weeks of gestation from the chronological
                                 age. Therefore, a 7-month-old, former 28 week gestational age
                                 infant has a corrected age of 4 months according to the following
                                 equation:


                                                                                                     Section II-26
Rehabilitative Services for Persons with Mental Illness                                                   Section II

                                     7 months - [(40 weeks) - 28 weeks) / 4 weeks]

                                     7 months - [(12) / 4 weeks]
                                     7 months - [3]

                                     4 months
                     e.    Results from an assessment specific to the suspected type of speech
                           production disorder, including all relevant scores, quotients and/or indexes, if
                           applicable. All errors specific to the type of speech production disorder must
                           be reported (e.g., positions, processes, motor patterns). (Review Section
                           228.414 — Accepted Tests for Speech-Language Therapy.)
                     f.    If applicable, test results should be adjusted for prematurity (less than 37
                           weeks gestation) if the child is 12 months of age or younger, and this should be
                           noted in the evaluation.
                     g.    Oral-peripheral speech mechanism examination, which includes a description
                           of the structure and function of orofacial structures.
                     h.    Formal screening of language skills. Examples include, but are not limited to,
                           the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.
                     i.    Formal or informal assessment of hearing, voice and fluency skills.
                     j.    An interpretation of the results of the evaluation including recommendations for
                           frequency and intensity of treatment.
                     k.    A description of functional strengths and limitations, a suggested treatment
                           plan and potential goals to address each identified problem.
                     l.    Signature and credentials of the therapist performing the evaluation.
              4.     SPEECH PRODUCTION (Voice): To establish medical necessity, results from a
                     comprehensive assessment in the suspected area of deficit must be reported. (Refer
                     to Section 228.410, part D, paragraphs 9-12 for required frequency of re-
                     evaluations.) A comprehensive assessment for Speech Production (Voice) disorder
                     must include:
                     a.    A medical evaluation to determine the presence or absence of a physical
                           etiology is a prerequisite for evaluation of voice disorder.
                     b.    Date of evaluation.
                     c.    Child’s name and date of birth.
                     d.    Diagnosis specific to therapy.
                     e.    Background information including pertinent medical history; and, if the child is
                           12 months of age or younger, gestational age. The child should be tested in
                           the child’s dominant language; if not, an explanation must be provided in the
                           evaluation.
                           NOTE: To calculate a child’s gestational age, subtract the number of
                                 weeks born before 40 weeks of gestation from the chronological
                                 age. Therefore, a 7-month-old, former 28 week gestational age
                                 infant has a corrected age of 4 months according to the following
                                 equation:

                                     7 months - [(40 weeks) - 28 weeks) / 4 weeks]
                                     7 months - [(12) / 4 weeks]
                                     7 months - [3]

                                     4 months
                     f.    Results from an assessment relevant to the suspected type of speech

                                                                                                      Section II-27
Rehabilitative Services for Persons with Mental Illness                                                   Section II

                           production disorder, including all relevant scores, quotients and/or indexes, if
                           applicable. (Review Section 228.414 — Accepted Tests for Speech-Language
                           Therapy.)
                     g.    If applicable, test results should be adjusted for prematurity (less than 37
                           weeks gestation) if the child is 12 months of age or younger, and this should be
                           noted in the evaluation.
                     h.    Oral-peripheral speech mechanism examination, which includes a description
                           of the structure and function of orofacial structures.
                     i.    Formal screening of language skills. Examples include, but are not limited to,
                           the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.
                     j.    Formal or informal assessment of hearing, articulation and fluency skills.
                     k.    An interpretation of the results of the evaluation including recommendations for
                           frequency and intensity of treatment.
                     l.    A description of functional strengths and limitations, a suggested treatment
                           plan and potential goals to address each identified problem.
                     m.    Signature and credentials of the therapist performing the evaluation.
              5.     SPEECH PRODUCTION (Fluency): To establish medical necessity, results from a
                     comprehensive assessment in the suspected area of deficit must be reported. (Refer
                     to Section 228.410, part D, paragraphs 9-12 for required frequency of re-
                     evaluations.) A comprehensive assessment for Speech Production (Fluency)
                     disorder must include:
                     a.    Date of evaluation.
                     b.    Child’s name and date of birth.
                     c.    Diagnosis specific to therapy.
                     d.    Background information including pertinent medical history; and, if the child is
                           12 months of age or younger, gestational age. The child should be tested in
                           the child’s dominant language; if not, an explanation must be provided in the
                           evaluation.
                           NOTE: To calculate a child’s gestational age, subtract the number of
                                 weeks born before 40 weeks of gestation from the chronological
                                 age. Therefore, a 7-month-old, former 28 week gestational age
                                 infant has a corrected age of 4 months according to the following
                                 equation:
                                     7 months - [(40 weeks) - 28 weeks) / 4 weeks]
                                     7 months - [(12) / 4 weeks]

                                     7 months - [3]

                                     4 months
                     e.    Results from an assessment specific to the suspected type of speech
                           production disorder, including all relevant scores, quotients and/or indexes, if
                           applicable. (Review Section 228.414 — Accepted Tests for Speech-Language
                           Therapy.)
                     f.    If applicable, test results should be adjusted for prematurity (less than 37
                           weeks gestation) if the child is 12 months of age or younger, and this should be
                           noted in the evaluation.
                     g.    Oral-peripheral speech mechanism examination, which includes a description
                           of the structure and function of orofacial structures.
                     h.    Formal screening of language skills. Examples include, but are not limited to,
                           the Fluharty-2, KLST-2, CELF-4 Screen or TTFC.

                                                                                                     Section II-28
Rehabilitative Services for Persons with Mental Illness                                                   Section II

                     i.    Formal or informal assessment of hearing, articulation and voice skills.
                     j.    An interpretation of the results of the evaluation including recommendations for
                           frequency and intensity of treatment.
                     k.    A description of functional strengths and limitations, a suggested treatment
                           plan and potential goals to address each identified problem.
                     l.    Signature and credentials of the therapist performing the evaluation.
              6.     ORAL MOTOR/SWALLOWING/FEEDING: To establish medical necessity, results
                     from a comprehensive assessment in the suspected area of deficit must be reported.
                     (Refer to Section 228.410, part D, paragraphs 9-12 for required frequency of re-
                     evaluations.) A comprehensive assessment for Oral Motor/Swallowing/Feeding
                     disorder must include:
                     a.    Date of evaluation.
                     b.    Child’s name and date of birth.
                     c.    Diagnosis specific to therapy.
                     d.    Background information including pertinent medical history; and, if the child is
                           12 months of age or younger, gestational age. The child should be tested in
                           the child’s dominant language; if not, an explanation must be provided in the
                           evaluation.
                           NOTE: To calculate a child’s gestational age, subtract the number of
                                 weeks born before 40 weeks of gestation from the chronological
                                 age. Therefore, a 7-month-old, former 28 week gestational age
                                 infant has a corrected age of 4 months according to the following
                                 equation:
                                     7 months - [(40 weeks) - 28 weeks) / 4 weeks]

                                     7 months - [(12) / 4 weeks]

                                     7 months - [3]
                                     4 months
                     e.    Results from an assessment specific to the suspected type of oral
                           motor/swallowing/feeding disorder, including all relevant scores, quotients
                           and/or indexes, if applicable. (Review Section 228.414 — Accepted Tests for
                           Speech-Language Therapy.)
                     f.    If swallowing problems and/or signs of aspiration are noted, then include a
                           statement indicating that a referral for a videofluoroscopic swallow study has
                           been made.
                     g.    If applicable, test results should be adjusted for prematurity (less than 37
                           weeks gestation) if the child is 12 months of age or younger, and this should be
                           noted in the evaluation.
                     h.    Formal or informal assessment of hearing, language, articulation, voice and
                           fluency skills.
                     i.    An interpretation of the results of the evaluation including recommendations for
                           frequency and intensity of treatment.
                     j.    A description of functional strengths and limitations, a suggested treatment
                           plan and potential goals to address each identified problem.
                     k.    Signature and credentials of the therapist performing the evaluation.
        D.    Interpretation and Eligibility: Ages Birth to 21
              1.     LANGUAGE: Two language composite or quotient scores (i.e., normed or
                     standalone) in the area of suspected deficit must be reported, with at least one being

                                                                                                      Section II-29
Rehabilitative Services for Persons with Mental Illness                                                     Section II

                     a norm-referenced, standardized test with good reliability and validity. (Use of two
                     one-word vocabulary tests alone will not be accepted.)
                     a.    For children age birth to three: criterion-referenced tests will be accepted as a
                           second measure for determining eligibility for language therapy.
                     b.    For children age three to 21, criterion-referenced tests will not be accepted as a
                           second measure when determining eligibility for language therapy. (When use
                           of standardized instruments is not appropriate, see Section 228.410, part D,
                           paragraph 8).
                     c.    Age birth to three: Eligibility for language therapy will be based upon a
                           composite or quotient score that is -1.5 standard deviations (SD) below the
                           mean or greater from a norm-referenced, standardized test, with corroborating
                           data from a criterion-referenced measure. When these two measures do not
                           agree, results from a third measure that corroborate the identified deficits are
                           required to support the medical necessity of services.
                     d.    Age three to 21: Eligibility for language therapy will be based upon 2
                           composite or quotient scores that are -1.5 standard deviations (SD) below the
                           mean or greater. When -1.5 SD or greater is not indicated by both of these
                           scores, a third standardized score indicating a -1.5 SD or greater is required to
                           support the medical necessity of services.
              2.     ARTICULATION AND/OR PHONOLOGY: Two tests and/or procedures must be
                     administered, with at least one being from a norm-referenced, standardized test with
                     good reliability and validity.
                     Eligibility for articulation and/or phonological therapy will be based upon standard
                     scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or
                     greater is not indicated by both of these tests, corroborating data from accepted
                     procedures can be used to support the medical necessity of services (review Section
                     228.414 — Accepted Tests for Speech-Language Therapy).
              3.     APRAXIA: Two tests and/or procedures must be administered, with at least one
                     being a norm-referenced, standardized test with good reliability and validity.
                     Eligibility for apraxia therapy will be based upon standard scores (SS) of -1.5 SD or
                     greater below the mean from two tests. When -1.5 SD or greater is not indicated by
                     both of these tests, corroborating data from a criterion-referenced test and/or
                     accepted procedures can be used to support the medical necessity of services
                     (review Section 228.414 — Accepted Tests for Speech-Language Therapy).
              4.     VOICE: Due to the high incidence of medical factors that contribute to voice
                     deviations, a medical evaluation is a requirement for eligibility for voice therapy.
                     Eligibility for voice therapy will be based upon a medical referral for therapy and a
                     functional profile of voice parameters that indicates a moderate or severe
                     deficit/disorder.
              5.     FLUENCY: At least one norm-referenced, standardized test with good reliability and
                     validity and at least one supplemental tool to address affective components.
                     Eligibility for fluency therapy will be based upon an SS of -1.5 SD below the mean or
                     greater on the standardized test.
              6.     ORAL MOTOR/SWALLOWING/FEEDING: An in-depth, functional profile of oral
                     motor structures and function.
                     Eligibility for oral-motor/swallowing/feeding therapy will be based upon an in-depth
                     functional profile of oral motor structures and function using a thorough protocol (e.g.,
                     checklist, profile) that indicates a moderate or severe deficit or disorder. When
                     moderate or severe aspiration has been confirmed by videofluoroscopic swallow
                     study, the patient can be treated for feeding difficulties via the recommendations set
                     forth in the swallow study report.

                                                                                                       Section II-30
Rehabilitative Services for Persons with Mental Illness                                                  Section II

                7.    All subtests, components and scores must be reported for all tests used for eligibility
                      purposes.
                8.    When administration of standardized, norm-referenced instruments is inappropriate,
                      the provider must submit an in-depth functional profile of the child’s communication
                      abilities. An in-depth functional profile is a detailed narrative or description of a
                      child’s communication behaviors that specifically explains and justifies the following:
                      a.    The reason standardized testing is inappropriate for this child,
                      b.    The communication impairment, including specific skills and deficits, and
                      c.    The medical necessity of therapy.
                      d.    Supplemental instruments from Accepted Tests for Speech-Language Therapy
                            may be useful in developing an in-depth functional profile.
                9.    Children (age birth to age 21) receiving services outside of the schools must be
                      evaluated annually.
                10.   Children (age birth to 24 months) in the Child Health Management Services (CHMS)
                      Program must be evaluated every 6 months.
                11.   Children (age three to 21) receiving services within schools as part of an Individual
                      Program Plan (IPP) or an Individual Education Plan (IEP) must have a full evaluation
                      every three years; however, an annual update of progress is required.
                12.   Children (age three to 21) receiving privately contracted services, apart from or in
                      addition to those within the schools, must have a full evaluation annually.
                13.   IQ scores are required for all children who are school age and receiving language
                      therapy. Exception: IQ scores are not required for children under ten (10) years of
                      age.

    228.411           Reserved                                                                       11-1-10


    228.412           Reserved                                                                       11-1-10


    228.413           Reserved                                                                       11-1-10


    228.414           Accepted Tests for Speech-Language Therapy                                     11-1-10

        Tests used must be norm-referenced, standardized, age appropriate and specific to the disorder
        being assessed. The following list of tests is not all-inclusive. When using a test that is not listed
        here, the provider must include an explanation and justification in the evaluation report to
        support the use of the chosen test. The Mental Measurement Yearbook (MMY) is the standard
        reference for determining the reliability and validity of the test(s) administered in the evaluation.
        Providers should refer to the MMY for additional information regarding specific tests. These
        definitions are applied to the lists of accepted tests:

             STANDARDIZED: Tests that are used to determine the presence or absence of deficits; any
              diagnostic tool or procedure that has a standardized administration and scoring process and
              compares results to an appropriate normative sample.

             SUPPLEMENTAL: Tests and tools that are used to further document deficits and support
              standardized results; any non-diagnostic tool that is a screening, a criterion-referenced
              measure, descriptive in design, a structured probe or an accepted clinical analysis procedure
              (see next paragraph). Supplemental tests may not supplant standard tests. Exception: A
              tool(s) from a supplemental list may be used to guide data collection for the purpose of
              generating an in-depth, functional profile. (See Section 228.410, part D, paragraph 8.)

             CLINICAL ANALYSIS PROCEDURES: Specific analysis methods used for in-depth
              examination of clinical data obtained during assessment and used to further document

                                                                                                      Section II-31
Rehabilitative Services for Persons with Mental Illness                                                Section II

             deficits and support standardized results. Clinical analysis procedures may not supplant
             standardized tests. Exception: Procedures from this list may be used to analyze data
             collected and assist in generating an in-depth, functional profile. (See Section 228.410, part
             D, paragraph 8.)

            CLINICAL OBSERVATIONS: Clinical observations have a supplemental role in the
             evaluation process and should always be included. They are especially important when
             standard scores do not accurately reflect a child’s deficits in order to qualify the child for
             therapy. A detailed narrative or description of the child’s communication behaviors (in-depth,
             functional profile) may constitute the primary justification of medical necessity.

            STANDARDIZED SCORING KEY:
             Mild: Scores between 84-78; -1.0 standard deviation

             Moderate: Scores between 77-71; -1.5 standard deviations
             Severe: Scores between 70-64; -2.0 standard deviations

             Profound: Scores of 63 or lower; -2.0+ standard deviations
        A.    Language Tests — Standardized (Newer editions of currently listed tests are also
              acceptable.)


                Test                                                                     Abbreviation
                Assessment of Language-Related Functional Activities                     ALFA
                Assessment of Literacy and Language                                      ALL
                Behavior Rating Inventory of Executive Function                          BRIEF
                Behavioural Assess of the Dysexecutive Syndrome for Children             BADS-C
                Brief Test of Head Injury                                                BTHI
                Children’s Communication Checklist [Diagnostic for pragmatics]           CCC
                Clinical Evaluation of Language Fundamentals — Preschool                 CELF-P
                Clinical Evaluation of Language Fundamentals, Fourth Edition             CELF-4
                Clinical Evaluation of Language Fundamentals, Third Edition              CELF-3
                Communication Abilities Diagnostic Test                                  CADeT
                Communication Activities of Daily Living, Second Edition                 CADL-2
                Comprehensive Assessment of Spoken Language                              CASL
                Comprehensive Receptive and Expressive Vocabulary Test, Second           CREVT-2
                Edition
                Comprehensive Test of Phonological Processing                            CTOPP
                Diagnostic Evaluation of Language Variation — Norm-Referenced            DELV-NR
                Emerging Literacy and Language Assessment                                ELLA
                Expressive Language Test                                                 ELT
                Expressive One-Word Picture Vocabulary Test, 2000 Edition                EOWPVT
                Fullerton Language Test for Adolescents, Second Edition                  FLTA
                Goldman-Fristoe-Woodcock Test of Auditory Discrimination                 GFWTAD
                HELP Test-Elementary                                                     HELP

                                                                                                    Section II-32
Rehabilitative Services for Persons with Mental Illness                                      Section II

                Test                                                           Abbreviation
                Illinois Test of Psycholinguistic Abilities, Third Edition     ITPA-3
                Language Processing Test — Revised                             LPT-R
                Language Processing Test, Third Edition                        LPT-3
                Listening Comprehension Test Adolescent                        LCT-A
                Listening Comprehension Test, Second Edition                   LCT-2
                Montgomery Assessment of Vocabulary Acquisition                MAVA
                Mullen Scales of Early Learning                                MSEL
                NOTE: Although the MSEL is an accepted standardized test, it
                      is felt by the Therapy Advisory Council (TAC) that an
                      additional test should be administered.
                Oral and Written Language Scales                               OWLS
                Peabody Picture Vocabulary Test, Fourth Edition                PPVT-4
                Peabody Picture Vocabulary Test, Third Edition                 PPVT-3
                Phonological Awareness Test                                    PAT
                Preschool Language Scale, Fourth Edition                       PLS-4
                Preschool Language Scale, Third Edition                        PLS-3
                Receptive One-Word Picture Vocabulary Test, Second Edition     ROWPVT-2
                Receptive-Expressive Emergent Language Test, Second Edition    REEL-2
                Receptive-Expressive Emergent Language Test, Third Edition     REEL-3
                Ross Information Processing Assessment — Primary               RIPA-P
                Ross Information Processing Assessment, Second Edition         RIPA-2
                Scales of Cognitive Ability for Traumatic Brain Injury         SCATBI
                Social Competence and Behavior Evaluation, Preschool Edition   SCBE
                Social Language Development Test — Elementary                  CLDT-E
                Social Responsiveness Scale                                    SRS
                Social Skills Rating System — Preschool & Elementary Level     SSRS-PE
                Social Skills Rating System — Secondary Level                  SSRS-S
                Strong Narrative Assessment Procedure                          SNAP
                Test of Adolescent and Adult Language, Third Edition           TOAL-3
                Test of Adolescent /Adult Word Finding                         TAWF
                Test for Auditory Comprehension of Language, Third Edition     TACL-3
                Test of Auditory Perceptual Skills — Revised                   TAPS-R
                Test of Auditory Perceptual Skills, Third Edition              TAPS-3
                Test of Auditory Reasoning and Processing Skills               TARPS
                Test of Early Language Development, Third Edition              TELD-3
                Test of Language Competence — Expanded Edition                 TLC-E
                Test of Language Development — Intermediate, Third Edition     TOLD-I:3

                                                                                          Section II-33
Rehabilitative Services for Persons with Mental Illness                                          Section II

                Test                                                             Abbreviation
                Test of Language Development — Primary, Third Edition            TOLD-P:3
                Test of Narrative Language                                       TNL
                Test of Phonological Awareness                                   TOPA
                Test of Pragmatic Language                                       TOPL
                Test of Pragmatic Language, Second Edition                       TOPL-2
                Test of Problem Solving — Adolescent                             TOPS-A
                Test of Problem Solving — Revised Elementary                     TOPS-R
                Test of Reading Comprehension, Third Edition                     TORC-2
                Test of Semantic Skills — Intermediate                           TOSS-I
                Test of Semantic Skills — Primary                                TOSS-P
                Test of Word Finding, Second Edition                             TWF-2
                Test of Word Knowledge                                           TOWK
                Test of Written Language, Third Edition                          TWL-3
                The Listening Test
                Wepman’s Auditory Discrimination Test, Second Edition            ADT
                Word Test — 2 Adolescent                                         WT2A
                Word Test — 2 Elementary                                         WT2E


        B.    Language Tests — Supplemental


                Test                                                             Abbreviation
                Assessment for Persons Profoundly or Severely Impaired           APPSI
                Behavior Analysis Language Instrument                            BALI
                Birth to Three Checklist
                Clinical Evaluation of Language Fundamentals-4 Screening Test    CELF-4
                Children’s Communication Checklist [Language Screener]           CCC-2
                CID Early Speech Perception                                      CID-ESP
                CID Speech Perception Evaluation                                 CID-SPICE
                CID Teacher Assessment of Grammatical Structures Communication   CID-TAGS
                Matrix
                Developmental Sentence Scoring [Lee]                             DSS
                Differential Screening Test for Processing                       DSTP
                Evaluating Acquired Skills in Communication — Revised            EASIC-R
                Evaluating Acquired Skills in Communication, Third Edition       EASIC-3
                Fluharty Preschool Speech and Language Screening Test, Second    Fluharty-2
                Edition
                Functional Communication Profile — Revised                       FCP-R


                                                                                              Section II-34
Rehabilitative Services for Persons with Mental Illness                                             Section II

                Test                                                                 Abbreviation
                Joliet 3-Minute Preschool Speech and Language Screen                 Joliet-P
                Joliet 3-Minute Speech and Language Screen — Revised                 Joliet-R
                Kindergarten Language Screening Test                                 KLST-2
                MacArthur Communicative Development Inventories                      CDIs
                MacArthur-Bates Communicative Development Inventories                CDIs
                Nonspeech Test for Receptive/Expressive Language                     Nonspeech
                Preschool Language Scale — 4 Screening Test
                Preverbal Assessment-Intervention Profile                            PAIP
                Reynell Developmental Language Scales                                Reynell
                Rossetti Infant-Toddler Language Scale                               Rossetti
                Screening Test of Adolescent Language                                STAL
                Social Communication Questionnaire                                   SCQ
                Social-Emotional Evaluation                                          SEE
                Test for Auditory Processing Disorders in Children — Revised         SCAN-C
                Token Test for Children, Second Edition                              TTFC-2


        C.    Language — Clinical Analysis Procedures — Language sampling and analysis, which may
              include the following:


                Test                                                                 Abbreviation
                Mean Length of Utterance                                             MLU
                Type Token Ratio                                                     TTR
                Developmental Sentence Score                                         DSS
                Structural analysis (Brown’s stages)
                Semantic analysis
                Discourse analysis


        D.    Speech Production Tests — Standardized (Newer editions of currently listed tests are also
              acceptable.)


                Test                                                                 Abbreviation
                Arizona Articulation Proficiency Scale, Third Edition                Arizona-3
                Assessment of Intelligibility of Dysarthric Speech                   AIDS
                Assessment of Phonological Processes — Revised                       APPS-R
                Bernthal-Bankson Test of Phonology                                   BBTOP
                Clinical Assessment of Articulation and Phonology                    CAAP
                Diagnostic Evaluation of Articulation and Phonology, U.S. Edition    DEAP
                Goldman-Fristoe Test of Articulation, Second Edition                 GFTA-2

                                                                                                 Section II-35
Rehabilitative Services for Persons with Mental Illness                                           Section II

                Test                                                               Abbreviation
                Hodson Assessment of Phonological Patterns, Third Edition          HAPP-3
                Kaufman Speech Praxis Test                                         KSPT
                Khan-Lewis Phonological Analysis                                   KLPA-2
                Photo Articulation Test, Third Edition                             PAT-3
                Slosson Articulation Language Test with Phonology                  SALT-P
                Smit-Hand Articulation and Phonology Evaluation                    SHAPE
                Structured Photographic Articulation Test II Featuring Dudsberry   SPAT-D II
                Stuttering Severity Instrument for Children and Adults             SSI-3
                Weiss Comprehensive Articulation Test                              WCAT


        E.    Speech Production Tests — Supplemental


                Test                                                               Abbreviation
                A-19 Scale for Children Who Stutter                                A-19
                Apraxia Profile
                Assessment of the Child’s Experience of Stuttering                 ACES
                CALMS Rating Scale for School-Age Children Who Stutter             CALMS
                Children’s Speech Intelligibility Measure                          CSIM
                CID Phonetic Inventory                                             CID-PI
                CID SPeech INtelligibility Evaluation                              CID-SPINE
                Communication Attitude Test for Preschool and Kindergarten         KiddyCAT
                Children Who Stutter
                Communication Attitude Test — Revised                              CAT-R
                Computerized Articulation and Phonology Evaluation System          CAPES
                Marshalla Oral Sensorimotor Test                                   MOST
                Modified Erickson Scale of Communication Attitudes
                Procedures for the Phonological Analysis of Children’s Language
                [Ingram]
                Screening Test for Developmental Apraxia of Speech, Second         STDAS-2
                Edition
                Secord Contextual Articulation Tests                               S-CAT
                Verbal-Motor Production Assessment for Children                    VMPAC
                Voice Assessment Protocol for Children and Adults                  VAP


        F.    Speech Production — Clinical Analysis Procedures — Speech sampling and analysis,
              which may include the following:
              1.     Debra Beckman’s oral-motor assessment procedures
              2.     Food chaining questionnaire
              3.     Instrumentation-based voice evaluation
                                                                                               Section II-36
Rehabilitative Services for Persons with Mental Illness                                                 Section II

              4.     Item and replica analysis
              5.     Percentage of consonants correct
              6.     Percentage of intelligibility
              7.     Percentage of phonemes correct
              8.     Percentage of syllables stuttered
              9.     Perceptual voice evaluation
              10.    Phonetic inventory
              11.    Phonological process analysis
              12.    Suzanne Evans-Morris oral-motor assessment procedures

    228.415          Intelligence Quotient (IQ) Testing                                             11-1-10

        Children receiving language intervention therapy must have cognitive testing once they reach
        ten (10) years of age. This also applies to home-schooled children. If the IQ score is higher
        than the qualifying language scores, the child qualifies for language therapy; if the IQ score is
        lower than the qualifying language test scores, the child would appear to be functioning at or
        above the expected level. In this case, the child may be denied for language therapy. If a
        provider determines that therapy is warranted, an in-depth functional profile must be
        documented. However, IQ scores are not required for children under ten (10) years of age.
        A.    IQ Tests — Traditional


                Test                                                                     Abbreviation
                Stanford-Binet                                                           S-B
                The Wechsler Preschool & Primary Scales of Intelligence, Revised         WPPSI-R
                Slosson
                Wechsler Intelligence Scale for Children, Third Edition                  WISC-III
                Kauffman Adolescent & Adult Intelligence Test                            KAIT
                Wechsler Adult Intelligence Scale, Third Edition                         WAIS-III
                Differential Ability Scales                                              DAS
                Reynolds Intellectual Assessment Scales                                  RIAS


        B.    Severe and Profound IQ Tests/Non-Traditional — Supplemental — Norm-Reference


                Test                                                                     Abbreviation
                Comprehensive Test of Nonverbal Intelligence                             CTONI
                Test of Nonverbal Intelligence — 1997                                    TONI-3
                Functional Linguistic Communication Inventory                            FLCI


    228.416          Recoupment Process                                                             11-1-05

        The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate
        the recoupment process for all claims that AFMC, the state Quality Improvement Organization
        (QIO), has denied because the records submitted do not support the claim of medical necessity.


                                                                                                     Section II-37
Rehabilitative Services for Persons with Mental Illness                                                 Section II

        Arkansas Medicaid will send the provider an Explanation of Recoupment Notice that will include
        the claim date of service, Medicaid beneficiary name and ID number, service provided, amount
        paid by Medicaid, amount to be recouped, and the reason the recoupment is initiated.

    229.000          Medicaid Beneficiary Appeal Process                                           10-13-03

        When an adverse decision is received, the beneficiary may request a fair hearing of the denial
        decision.

        The appeal request must be in writing and received by the Appeals and Hearings Section of the
        Department of Human Services within thirty days of the date on the letter explaining the denial of
        services. View or print the Appeals and Hearings Section contact information.

    229.100          Electronic Signatures                                                          10-8-10

        Medicaid will accept electronic signatures provided the electronic signatures comply with
        Arkansas Code 25-31-103.


    230.000          PRIOR AUTHORIZATION (PA) AND EXTENSION OF
                     BENEFITS

    231.000          Introduction to Prior Authorization and Extension of Benefits                   7-1-10

        The Division of Medical Services contracts with ValueOptions to complete the prior authorization
        and extension of benefit processes.
        When a provider requests PA for services to be provided via telemedicine, the procedure codes
        and modifiers (if any) listed below must be shown on the claim form, ―telemedicine‖ must be
        specified on the request.

        A request for prior authorization for services to be provided to a foster child must specify that the
        request is for a foster child. A request for services to be provided to a child in the custody of the
        Division of Youth Services (DYS) must specify DYS custody.

    231.100          Prior Authorization and Extension of Benefits                                   7-1-10

        Prior Authorization is required for certain services provided to Medicaid-eligible individuals.
        Extension of benefits is required for all other services when the maximum benefit for the service
        is exhausted. Yearly service benefits are based on the state fiscal year running from July 1 to
        June 30. Extension of Benefits is also required whenever a beneficiary exceeds eight hours of
        outpatient services in one 24-hour day, with the exception of crisis intervention, crisis
        stabilization intervention by a mental health professional, and crisis stabilization intervention by
        paraprofessional.
        Prior authorization and extension requests must be sent to ValueOptions for beneficiaries under
        the age of 21. View or print ValueOptions contact information. Information related to clinical
        management guidelines and authorization request processes is available at
        www.valueoptions.com.

        Prior authorization and extension requests must be sent to ValueOptions for beneficiaries age 21
        and over. View or print ValueOptions contact information. Information related to clinical
        management guidelines and authorization request processes is available at
        www.valueoptions.com.

        Procedure codes requiring prior authorization:

         National Codes                    Required Modifier           Service Title


                                                                                                     Section II-38
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National Codes                    Required Modifier           Service Title
         90846                             HA, U3,                     Marital/Family Therapy without
         90846                             —                           patient present
         90846                             U7 (telemedicine )
         90853                             HA, U1                      Group Outpatient – Group
         90853                             —                           Psychotherapy
         90862                             HA, HQ                      Group Outpatient –
                                                                       Pharmacologic Management by
                                                                       Physician
         H2012                             HA                          Therapeutic Day/Acute Day
         H2012                             UA                          Treatment
         90887                             HA                          Collateral Intervention, MHP
         90887                             U7 (telemedicine)
         90887                             HA, UB                      Collateral Intervention, MHPP
         H2015                             HA, U5                      Intervention, MHP
         H2015                             U6
         H2015                             U7 (telemedicine)
         H2015                             HA, U1                      Intervention, MHPP
         H2015                             U2
         H2017                             HA, U1                      Rehabilitative Day Service
         H2017                             —


        Procedure codes requiring Extension of Benefits:

         National Codes        Required Modifier          Service Title                 Yearly Maximum
         90801                 HA, U1                     Mental Health                 16
         90801                 U7 (telemedicine)          Evaluation/Diagnosis
         96101                 HA, UA                     Psychological Evaluation      32
         90885                 HA, U2                     Master Treatment Plan         8

         90887                 HA, U2                     Interpretation of Diagnosis   16
         90887                 U3, U7 (telemedicine)

         H0004                                            Individual Psychotherapy      48
         H0004                 HA
         H0004                 U7 (telemedicine)
         90847                 HA, U3                     Marital/Family Therapy        48
         90847                 —                          with patient present
         90847                 U7 (telemedicine)
         H2011                 HA                         Crisis Intervention           72
         H2011                 U7 (telemedicine)




                                                                                                      Section II-39
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National Codes        Required Modifier          Service Title                   Yearly Maximum
         T1023                 HA, U1                     Psychiatric Diagnostic          1
         T1023                 U7 (telemedicine)          Assessment (Note that
                                                          code T1023-HA,U1 was
                                                          formerly applied to
                                                          Assessment and
                                                          Treatment Plan/Plan of
                                                          Care)
         99201                 HA, UB                     Physical Examination            12
         99202                 HA, UB
         99203                 HA, UB
         99204                 HA, UB
         99212                 HA, UB
         99213                 HA, UB
         99214                 HA, UB

         AND
         99201                 HA, SA
         99202                 HA, SA
         99203                 HA, SA
         99204                 HA, SA
         99212                 HA, SA
         99213                 HA, SA
         99214                 HA, SA
         90862                 HA                         Pharmacologic                   24
         90862                 —                          Management
         90862                 HA, UB
         90862                 U7 (telemedicine)
         90885                 HA                         Periodic Review of Master       10
         90885                 HA, U1                     treatment plan
         36415                 HA                         Routine Venipuncture for        12
                                                          Collection of Specimen
         H2011                 HA, U6                     Crisis Stabilization, MHP       72
         H2011                 U2
         H2011                 U2, U7 (telemedicine)
         H2011                 HA, U5                     Crisis Stabilization,           72
         H2011                 U1
                                                          MHPP



    240.000          REIMBURSEMENT                                                                   10-4-09

        Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum
        allowable for each procedure.
        Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the
        service is provided and upon accurate completeness of the claim filed for the service. The
        provider is responsible for verifying that the beneficiary is eligible for Medicaid prior to rendering
        services.
        A.    Outpatient Services

              Fifteen-Minute Units

                                                                                                       Section II-40
Rehabilitative Services for Persons with Mental Illness                                                  Section II

              RSPMI services are billed on a per unit basis. A unit of service for an outpatient service is
              fifteen (15) minutes unless otherwise stated. Any unit less than five (5) minutes in duration
              is not considered a valid length of service and should not be submitted to Medicaid for
              payment. To determine how many units should be submitted on the claim, follow these
              steps. Begin by totaling the number of minutes of service rendered and divide by fifteen
              (15). If the remainder is five (5) or greater, round up to the next highest unit, but if the
              remainder is less than five (5), the quotient will be the valid units of service.

              Providers may collectively bill for a single date of service but may not collectively bill for
              spanning dates of service. For example, an RSPMI service may occur on behalf of a
              beneficiary on Monday and then again on Tuesday. The RSPMI provider may bill for the
              total amount of time spent on Monday and the total amount of time spent on Tuesday but
              may not bill for the total amount of time spent both days as a single date of service. The
              maximum allowable for a procedure is the same for all RSPMI providers.

              Documentation in the beneficiary’s record must reflect exactly how the number of units is
              determined.

              No more than four (4) units may be billed for a single hour per beneficiary or provider of the
              service.

        B.    Inpatient Services

              The length of time and number of units that may be billed for inpatient hospital visits are
              determined by the description of the service in Current Procedural Terminology (CPT).

    241.000          Rate Appeal Process                                                           10-13-03

        A provider may request reconsideration of a Program decision by writing to the Assistant
        Director, Division of Medical Services. This request must be received within 20 calendar days
        following the application of policy and/or procedure or the notification of the provider of its rate.
        Upon receipt of the request for review, the Assistant Director will determine the need for a
        Program/Provider conference and will contact the provider to arrange a conference if needed.
        Regardless of the Program decision, the provider will be afforded the opportunity for a
        conference, if he or she so wishes, for a full explanation of the factors involved and the Program
        decision. Following review of the matter, the Assistant Director will notify the provider of the
        action to be taken by the Division within 20 calendar days of receipt of the request for review or
        the date of the Program/Provider conference.

        If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the
        provider may then appeal the question to a standing Rate Review Panel, established by the
        Director of the Division of Medical Services, which will include one member of the Division of
        Medical Services, a representative of the provider association and a member of the Department
        of Human Services (DHS) Management Staff, who will serve as chairman.

        The request for review by the Rate Review Panel must be postmarked within 15 calendar days
        following the notification of the initial decision by the Assistant Director, Division of Medical
        Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days
        after receipt of a request for such appeal. The question(s) will be heard by the panel and a
        recommendation will be submitted to the Director of the Division of Medical Services.


    250.000          BILLING PROCEDURES

    251.000          Introduction to Billing                                                         7-1-07

        Rehabilitative Services for Persons with Mental Illness (RSPMI) providers use the CMS-1500
        form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid


                                                                                                      Section II-41
Rehabilitative Services for Persons with Mental Illness                                                  Section II

        beneficiaries. Each claim may contain charges for only one beneficiary. View a CMS-1500
        sample form.
        Section III of this manual contains information about Provider Electronic Solutions (PES) and
        other available options for electronic claim submission.

    252.000          CMS-1500 Billing Procedures

    252.100          Procedure Codes for Types of Covered Services                                  10-4-09

        Covered RSPMI services are outpatient services. Specific RSPMI services are available to
        inpatient hospital patients (as outlined in Sections 240.000 and 220.100), through telemedicine,
        and to nursing home and ICF/MR residents. RSPMI services are billed on a per unit basis.
        Unless otherwise specified in this manual or the appropriate CPT or HCPCS book, one unit
        equals 15 minutes. All services must be provided by at least the minimum staff within the
        licensed or certified scope of practice to provide the service.

        NOTE: RSPMI providers will continue to use modifiers 22 and 52. Effective for claims
              received on or after December 5, 2005, modifier 22 will be replaced with UA and
              modifier 52 will be replaced with UB.

    252.110          Outpatient Procedure Codes                                                     10-5-09


         National      Required
         Code          Modifier        Definition
         92506         HA              Diagnosis: Speech Evaluation
                                       1 unit = 30 minutes
                                       Maximum units per day: 4
                                       Maximum units per state fiscal year (SFY) = 4 units
         90801         HA, U1          SERVICE: Mental Health Evaluation/Diagnosis (Formerly
                                       known only as Diagnosis)
                                       DEFINITION: The cultural, developmental, age and disability -
                                       relevant clinical evaluation and determination of a beneficiary's
                                       mental status; functioning in various life domains; and an axis five
                                       DSM diagnostic formulation for the purpose of developing a plan
                                       of care. This service is required prior to provision of all other
                                       mental health services with the exception of crisis interventions.
                                       Services are to be congruent with the age, strengths, necessary,
                                       accommodations for disability, and cultural framework of the
                                       beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8,
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 16
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                              Date of Service
                                              Start and stop times of the face to face encounter with the
                                               beneficiary and the interpretation time for diagnostic
                                               formulation

                                                                                                      Section II-42
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                              Place of service
                                              Identifying information
                                              Referral reason
                                              Presenting problem (s), history of presenting problem(s),
                                               including duration, intensity, and response(s) to prior
                                               treatment
                                              Culturally- and age-appropriate psychosocial history and
                                               assessment
                                              Mental status/Clinical observations and impressions
                                              Current functioning and strengths in specified life domains
                                              DSM diagnostic impressions to include all five axes
                                              Treatment recommendations
                                              Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: This service may be billed for face-to-
                                       face contact as well as for time spent obtaining necessary
                                       information for diagnostic purposes; however, this time may NOT
                                       be used for development or submission of required paperwork
                                       processes (i.e. Prior Authorization requests, master treatment
                                       plans, etc.).
         90801         U7              Mental Health Evaluation/Diagnosis: Use the above definition
                                       and requirements.
                                       Additional information: Use code 90801 with modifier ―U7‖ to claim
                                       for services provided via telemedicine only. Note: Telemedicine
                                       POS 99
         96101         HA, UA          SERVICE: Psychological Evaluation (Formerly Diagnosis –
                                       Psychological Test/Evaluation and Diagnosis – Psychological
                                       Testing Battery)
                                       DEFINITION: A Psychological Evaluation employs standardized
                                       psychological tests conducted and documented for evaluation,
                                       diagnostic, or therapeutic purposes. The evaluation must be
                                       medically necessary, culturally relevant; with reasonable
                                       accommodations for any disability, provide information relevant to
                                       the beneficiary's continuation in treatment, and assist in treatment
                                       planning. All psychometric instruments must be administered,
                                       scored, and interpreted by the qualified professional.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 16
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 32
                                       ALLOWABLE PLACES OF SERVICE: Office (11)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                             Date of Service
                                             Start and stop times of actual encounter with beneficiary
                                             Start and stop times of scoring, interpretation and report
                                              preparation
                                             Place of service
                                             Identifying information
                                             Rationale for referral
                                             Presenting problem(s)
                                             Culturally- and age-appropriate psychosocial history and
                                              assessment
                                             Mental status/Clinical observations and impressions

                                                                                                     Section II-43
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National      Required
         Code          Modifier        Definition
                                               Psychological tests used, results, and interpretations, as
                                                indicated
                                               Axis Five DSM diagnostic impressions
                                               Treatment recommendations and findings related to
                                                rationale for service and guided by the master treatment
                                                plan and test results
                                               Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: Medical necessity for this service is
                                       met when the service is necessary to establish a differential
                                       diagnosis of behavioral or psychiatric conditions, when the history
                                       and symptomatology are not readily attributable to a particular
                                       psychiatric diagnosis and the questions to be answered by the
                                       evaluation could not be resolved by a psychiatric/diagnostic
                                       interview, observation in therapy, or an assessment for level of
                                       care at a mental health facility,
                                       Or
                                       Medical necessity is met when the beneficiary has demonstrated
                                       a complexity of issues related to cognitive functioning or the
                                       impact of a disability on a condition or behavior and the service is
                                       necessary to develop treatment recommendations after the
                                       beneficiary has received various treatment services and
                                       modalities, has not progressed in treatment, and continues to be
                                       symptomatic.
                                       Medicaid WILL NOT reimburse evaluations or testing that is
                                       considered primarily educational. Such services are those used to
                                       identify specific learning disabilities and developmental disabilities
                                       in beneficiaries who have no presenting behavioral or psychiatric
                                       symptoms which meet the need for mental health treatment
                                       evaluation. This type of evaluation and testing is provided by local
                                       school systems under applicable state and federal laws and rules.
                                       Psychological Evaluation services that are ordered strictly as a
                                       result of court-ordered services are not covered unless medical
                                       necessity criteria are met. Psychological Evaluation services for
                                       employment, disability qualification, or legal/court related
                                       purposes are not reimbursable by Medicaid as they are not
                                       considered treatment of illness. A Psychological Evaluation report
                                       must be completed within fourteen (14) calendar days of the
                                       examination; documented; clearly identified as such; and
                                       signed/dated by the staff completing the evaluation. This service
                                       constitutes both face to face time administering tests to the
                                       beneficiary and time interpreting these test results and preparing
                                       the report.
         T1023         HA, U1          SERVICE: Psychiatric Diagnostic Assessment (Note that
                                       code T1023-HA,U1 was formerly applied to Assessment and
                                       Treatment Plan/Plan of Care)
                                       DEFINITION: A direct face-to-face service contact occurring
                                       between the physician and the beneficiary for the purpose of
                                       evaluation. Psychiatric Diagnostic Assessment includes a history,
                                       mental status, and a disposition, and may include communication
                                       with family or other sources, ordering and medical interpretation of
                                       laboratory or other medical diagnostic studies. (See Section
                                       224.000 for requirements.)
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: This
                                       service must be billed as 1 per episode.

                                                                                                       Section II-44
Rehabilitative Services for Persons with Mental Illness                                                Section II

         National      Required
         Code          Modifier        Definition
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS:
                                       Date of Service
                                       Start and stop times
                                       Place of service
                                       Diagnosis
                                       Diagnostic Impression
                                       Psychiatric (re)assessment
                                       Functional (re)assessment
                                       Discharge criteria
                                       Physician's signature indicating medical necessity/credentials/date
                                       of signature
                                       NOTES and COMMENTS: The beneficiary must be reassessed,
                                       reviewed, and recertified at least every year.
         T1023         U7              SERVICE: Psychiatric Diagnostic Assessment (Note that
                                       code T1023-HA,U1 was formerly applied to Assessment and
                                       Treatment Plan/Plan of Care):
                                       Use the above definition and requirements.
                                       Additional Information: Use code T1023 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         90885         HA, U2          SERVICE: Master Treatment Plan
                                       DEFINITION: A developed plan in cooperation with the
                                       beneficiary (parent or guardian if the beneficiary is under 18), to
                                       deliver specific mental health services to the beneficiary to
                                       restore, improve or stabilize the beneficiary's mental health
                                       condition. The plan must be based on individualized service
                                       needs identified in the completed Mental Health Diagnostic
                                       Evaluation. The plan must include goals for the medically
                                       necessary treatment of identified problems, symptoms and mental
                                       health conditions. The plan must identify individuals or treatment
                                       teams responsible for treatment, specific treatment modalities
                                       prescribed for the beneficiary, time limitations for services, and
                                       documentation of medical necessity by the supervising physician
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 8
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54);
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service (date plan is developed)
                                               Start and stop times for development of plan
                                               Place of service
                                               Diagnosis
                                               Beneficiary's strengths and needs
                                               Treatment goal(s) developed in cooperation with and as

                                                                                                    Section II-45
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                                stated by beneficiary that are related specifically to the
                                                beneficiary's strengths and needs
                                               Measurable objectives
                                               Treatment modalities — The specific services that will be
                                                used to meet the measurable objectives
                                               Projected schedule for service delivery, including amount,
                                                scope, and duration
                                               Credentials of staff who will be providing the services
                                               Discharge criteria
                                               Signature/credentials of staff drafting the document and
                                                primary staff who will be delivering or supervising the
                                                delivery of the specific services/ date of signature(s)
                                               Beneficiary's signature (or signature of parent, guardian,
                                                or custodian of beneficiaries under the age of 18)/ date of
                                                signature
                                               Physician's signature indicating medical necessity /date of
                                                signature
                                       NOTES and COMMENTS: The service formerly coded as T1023
                                       and titled ―Assessment and Treatment Plan/Plan of Care‖ is now
                                       incorporated into this service. This service may be billed one (1)
                                       time upon entering care and once yearly thereafter. The master
                                       treatment plan must be reviewed every ninety (90) calendar days
                                       or more frequently if there is documentation of significant acuity
                                       changes in clinical status requiring an update/change in the
                                       beneficiary's master treatment plan. It is the responsibility of the
                                       primary mental health professional to insure that all
                                       paraprofessionals working with the client have a clear
                                       understanding and work toward the goals and objectives stated on
                                       the treatment plan.
         90885         HA              SERVICE: Periodic Review of Master Treatment Plan
                                       DEFINITION: The periodic review and revision of the master
                                       treatment plan, in cooperation with the beneficiary, to determine
                                       the beneficiary's progress or lack of progress toward the master
                                       treatment plan goals and objectives; the efficacy of the services
                                       provided; and continued medical necessity of services. This
                                       includes a review and revision of the measurable goals and
                                       measurable objectives directed at the medically necessary
                                       treatment of identified symptoms/mental health condition,
                                       individuals or treatment teams responsible for treatment, specific
                                       treatment modalities, and necessary accommodations that will be
                                       provided to the beneficiary, time limitations for services, and the
                                       medical necessity of continued services. Services are to be
                                       congruent with the age, strengths, necessary accommodations for
                                       any disability, and cultural framework of the beneficiary and
                                       his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 2
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 10
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for

                                                                                                     Section II-46
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       additional requirements):
                                       Completed by the primary MHP (If not, then must have a
                                       rationale for another MHP completing the documentation and
                                       only with input from the primary MHP)
                                               Date of service
                                               Start and stop times for review and revision of plan
                                               Place of service
                                               Diagnosis and pertinent interval history
                                               Beneficiary's updated strengths and needs
                                               Progress/Regression with regard to treatment goal(s) as
                                                documented in the master.
                                               Progress/Regression of the measurable objectives as
                                                documented in the master treatment plan
                                               Individualized rationale to support the medical necessity of
                                                continued services
                                               Updated schedule for service delivery, including amount,
                                                scope, and duration
                                               Credentials of staff who will be providing the services
                                               Modifications to discharge criteria
                                               Signature/credentials of staff drafting the document and
                                                primary staff who will be delivering or supervising the
                                                delivery of the specific services/date of signature(s)
                                               Beneficiary's signature (or signature of parent, guardian,
                                                or custodian of beneficiaries under the age of 18)/date of
                                                signature(s)
                                               Physician's signature indicating continued medical
                                                necessity/date of signature
                                       NOTES and COMMENTS: This service must be provided every
                                       ninety (90) days or more frequently if there is documentation of
                                       significant change in acuity or change in clinical status requiring
                                       an update/change in the beneficiary's master treatment plan. If
                                       progress is not documented, then modifications should be made
                                       in the master treatment plan or rationale why continuing to provide
                                       the same type and amount of services is expected to achieve
                                       progress/outcome. It is the responsibility of the primary mental
                                       health professional to insure that all paraprofessionals working
                                       with the client have a clear understanding and work toward the
                                       goals and objectives stated on the treatment plan.
         90885         HA, U1          Periodic Review of Master Treatment Plan
                                       Apply the above description.
                                       Additional information: Use code 90885 with modifier ―U1‖ to
                                       claim for this service when provided by a non-physician.
         90887         HA, U2          SERVICE: Interpretation of Diagnosis
                                       DEFINITION: A face-to face therapeutic intervention provided to
                                       a beneficiary in which the results/implications/diagnoses from a
                                       mental health diagnosis evaluation or a psychological evaluation
                                       are explained by the professional who administered the
                                       evaluation. Services are to be congruent with the age, strengths,
                                       necessary accommodations, and cultural framework of the
                                       beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 16

                                                                                                      Section II-47
Rehabilitative Services for Persons with Mental Illness                                                Section II

         National      Required
         Code          Modifier        Definition
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                              Start and stop times of face to face encounter with
                                               beneficiary and/or parents or guardian
                                              Date of service
                                              Place of service
                                              Participants present and relationship to beneficiary
                                              Diagnosis
                                              Rationale for and intervention used that must coincide with
                                               the master treatment plan or proposed master treatment
                                               plan or recommendations.
                                              Participant response and feedback
                                              Any changes or revision to the master treatment plan,
                                               diagnosis, or medication(s)
                                              Staff signature/credentials/date of signature(s)
                                       NOTES AND COMMENTS: For beneficiaries under the age of 18,
                                       the time may be spent face-to-face with the beneficiary; the
                                       beneficiary and the parent(s) or guardian(s); or alone with the
                                       parent(s) or guardian(s). For beneficiaries over the age of 18, the
                                       time may be spent face-to-face with the beneficiary and the
                                       spouse, legal guardian or significant other.
         90887         U3, U7          Interpretation of Diagnosis
                                       Use above definition and requirements
                                       Additional information: Use code 90887 with modifier ―U3, U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         H0004         HA              SERVICE: Individual Psychotherapy
                                       DEFINITION Face-to-face treatment provided by a licensed
                                       mental health professional on an individual basis. Services
                                       consist of structured sessions that work toward achieving mutually
                                       defined goals as documented in the master treatment plan.
                                       Services are to be congruent with the age, strengths, needed
                                       accommodations necessary for any disability, and cultural
                                       framework of the beneficiary and his/her family. The treatment
                                       service must reduce or alleviate identified symptoms, maintain or
                                       improve level of functioning, or prevent deterioration.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 48
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31)
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54)
                                       AGE GROUP(S): U21, but not for beneficiaries under the age of
                                       3 except in documented exceptional cases
                                       REQUIRED DOCUMENTATION (See Section 226.200 for
                                       additional requirements):

                                                                                                    Section II-48
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                              Date of Service
                                              Start and stop times of face to face encounter with
                                               beneficiary
                                              Place of service
                                              Diagnosis and pertinent interval history
                                              Brief mental status and observations
                                              Rationale and description of the intervention used that
                                               must coincide with the master
                                              Beneficiary's response to intervention that includes current
                                               progress or regression and prognosis
                                              Any revisions indicated for the master treatment plan,
                                               diagnosis, or medication(s)
                                              Plan for next individual therapy session, including any
                                               homework assignments and/or advanced psychiatric
                                               directive
                                              Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: Services provided must be congruent
                                       with the objectives and interventions articulated on the most
                                       recent treatment plan. Services must be consistent with
                                       established behavioral healthcare standards. Individual
                                       Psychotherapy is not permitted with beneficiaries who do not have
                                       the cognitive ability to benefit from the service.
         H0004         —               Individual Psychotherapy
                                       Use above definition and requirements.
                                       Additional information: Use code H0004 with no modifier to claim
                                       for services provided to beneficiaries ages 21 and over.
         H0004         U7              Individual Psychotherapy
                                       Use above definition and requirements.
                                       Additional information: Use code H0004 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         90846         HA, U3          SERVICE: Marital/Family Psychotherapy – Beneficiary is not
                                       present
                                       DEFINITION: Face-to-face treatment provided to more than one
                                       member of a family simultaneously in the same session or
                                       treatment with an individual family member (i.e. Spouse or Single
                                       Parent) that is specifically related to achieving goals identified on
                                       the beneficiary's master treatment plan. The identified beneficiary
                                       is not present for this service. Services are to be congruent with
                                       the age, strengths, needed accommodations for any disability,
                                       and cultural framework of the beneficiary and his/her family.
                                       These services identify and address marital/family dynamics and
                                       improve/strengthen marital/family interactions and functioning in
                                       relationship to the beneficiary, the beneficiary's condition and the
                                       condition's impact on the marital/family relationship.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
                                       REQUIRES PRIOR AUTHORIZATION
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14)
                                       AGE GROUP(S): U21

                                                                                                      Section II-49
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Start and stop times of actual encounter with
                                                spouse/family
                                               Place of service
                                               Participants present
                                               Nature of relationship with beneficiary
                                               Rationale for excluding the identified beneficiary
                                               Diagnosis and pertinent interval history
                                               Rationale for and intervention used that must coincide with
                                                the master treatment plan and improve the impact the
                                                beneficiary's condition has on the spouse/family and/or
                                                improve marital/family interactions between the beneficiary
                                                and the spouse/family.
                                               Spouse/Family response to intervention that includes
                                                current progress or regression and prognosis
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for next session, including any homework
                                                assignments and/or crisis plans
                                               HIPPA compliant Release of information forms,
                                                completed, signed and dated
                                               Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: Information to support the
                                       appropriateness of excluding the identified beneficiary must be
                                       documented in the service note and medical record. Natural
                                       supports may be included in these sessions when the nature of
                                       the relationship with the beneficiary and that support’s expected
                                       role in attaining treatment goals is documented. Only one
                                       beneficiary per family per therapy session may be billed.
         90846         —               Marital/Family Psychotherapy – Beneficiary is not present
                                       Use the above definition and requirements.
                                       Additional information: Use code 90846 with no modifier to claim
                                       for services provided to beneficiaries ages 21 and over.
         90846         U7              Marital/Family Psychotherapy – Beneficiary is not present
                                       Use the above definition and requirements.
                                       Additional information: Use code 90846 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         90847         HA, U3          SERVICE: Marital/Family Psychotherapy – Beneficiary is
                                       present
                                       DEFINITION: Face-to-face treatment provided to more than one
                                       member of a family simultaneously in the same session or
                                       treatment with an individual family member (i.e. Spouse or Single
                                       Parent) that is specifically related to achieving goals identified on
                                       the beneficiary's master treatment plan. The identified beneficiary
                                       must be present for this service. Services are to be congruent
                                       with the age, strengths, needed accommodations for disability,
                                       and cultural framework of the beneficiary and his/her family.
                                       These services are to be utilized to identify and address

                                                                                                      Section II-50
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       marital/family dynamics and improve/strengthen marital/family
                                       interactions and functioning in relationship to the beneficiary, the
                                       beneficiary's condition and the condition's impact on the
                                       marital/family relationship.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 48
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14)
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Start and stop times of actual encounter with beneficiary
                                                and spouse/family
                                               Place of service
                                               Participants present and relationship to beneficiary
                                               Diagnosis and pertinent interval history
                                               Brief mental status of beneficiary and observations of
                                                beneficiary with spouse/family
                                               Rationale for, and description of intervention used that
                                                must coincide with the master treatment plan and improve
                                                the impact the beneficiary's condition has on the
                                                spouse/family and/or improve marital/family interactions
                                                between the beneficiary and the spouse/family.
                                               Beneficiary and spouse/family's response to intervention
                                                that includes current progress or regression and prognosis
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for next session, including any homework
                                                assignments and/or crisis plans
                                               Staff signature/credentials/date of signature
                                               HIPAA compliant release of Information, completed,
                                                signed and dated
                                       NOTES and COMMENTS: Natural supports may be included in
                                       these sessions if justified in service documentation and if
                                       supported in the master treatment plan. Only one beneficiary per
                                       family per therapy session may be billed.
                                       Additional information: Use code 90847 with modifiers ―HA, U3‖
                                       to claim for services provided to beneficiaries under age 21.
         90847         —               Marital/Family Psychotherapy – Beneficiary is present
                                       Use the above definition and requirements.
                                       Additional information: Use code 90847 with no modifier to claim
                                       for services provided to beneficiaries ages 21 and over.
         90847         U7              Marital/Family Psychotherapy – Beneficiary is present
                                       Use the above definition and requirements.
                                       Additional information: Use code 90847 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Telemedicine
                                       POS 99
         92507         HA              Individual Outpatient – Speech Therapy, Speech Language

                                                                                                     Section II-51
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       Pathologist
                                       Scheduled individual outpatient care provided by a licensed
                                       speech pathologist supervised by a physician to a Medicaid-
                                       eligible beneficiary for the purpose of treatment and remediation
                                       of a communicative disorder deemed medically necessary. See
                                       the Occupational, Physical and Speech Therapy Program
                                       Provider Manual for specifics of the speech therapy services.
         92507         HA, UB          Individual Outpatient – Speech Therapy, Speech Language
                                       Pathologist Assistant
                                       Scheduled individual outpatient care provided by a licensed
                                       speech pathologist assistant supervised by a qualified speech
                                       language pathologist to a Medicaid-eligible beneficiary for the
                                       purpose of treatment and remediation of a communicative
                                       disorder deemed medically necessary. See the Occupational,
                                       Physical and Speech Therapy Program Provider Manual for
                                       specifics of the speech therapy services.
         92508         HA              Group Outpatient – Speech Therapy, Speech Language
                                       Pathologist
                                       Contact between a group of Medicaid-eligible beneficiaries and a
                                       speech pathologist for the purpose of speech therapy and
                                       remediation. See the Occupational, Physical and Speech
                                       Therapy Provider Manual for specifics of the speech therapy
                                       services.
         92508         HA, UB          Group Outpatient – Speech Therapy, Speech Language
                                       Pathologist Assistant
                                       Contact between a group of Medicaid-eligible beneficiaries and a
                                       speech pathologist assistant for the purpose of speech therapy
                                       and remediation. See the Occupational, Physical and Speech
                                       Therapy Provider Manual for specifics of the speech therapy
                                       services.
         90853         HA, U1          SERVICE: Group Outpatient – Group Psychotherapy
                                       DEFINITION: Face-to-face interventions provided to a group of
                                       beneficiaries on a regularly scheduled basis to improve behavioral
                                       or cognitive problems which either cause or exacerbate mental
                                       illness. The professional uses the emotional interactions of the
                                       group's members to assist them in implementing each
                                       beneficiary's master treatment plan. Services are to be congruent
                                       with the age, strengths, needed accommodation for any disability,
                                       and cultural framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); School (03);
                                       Homeless Shelter (04); Assisted Living Facility (13); Group Home
                                       (14);
                                       AGE GROUP(S): Ages 4 – 20; Under age 4 by prior authorized
                                       medically needy exception
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Start and stop times of actual group encounter that
                                                includes identified beneficiary
                                                                                                     Section II-52
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                               Place of service
                                               Number of participants
                                               Diagnosis
                                               Focus of group
                                               Brief mental status and observations
                                               Rationale for group intervention and intervention used that
                                                must coincide with master treatment plan
                                               Beneficiary's response to the group intervention that
                                                includes current progress or regression and prognosis
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for next group session, including any homework
                                                assignments
                                               Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: This does NOT include psychosocial
                                       groups. Beneficiaries eligible for Group Outpatient – Group
                                       Psychotherapy must demonstrate the ability to benefit from
                                       experiences shared by others, the ability to participate in a group
                                       dynamic process while respecting the others' rights to
                                       confidentiality, and must be able to integrate feedback received
                                       from other group members. For groups of beneficiaries aged 18
                                       and over, the minimum number that must be served in a specified
                                       group is 2. The maximum that may be served in a specified group
                                       is 12. For groups of beneficiaries under 18 years of age, the
                                       minimum number that must be served in a specified group is 2.
                                       The maximum that may be served in a specified group is 10. A
                                       beneficiary must be 4 years of age to receive group therapy.
                                       Group treatment must be age and developmentally appropriate,
                                       (i.e.: 16 year olds and 4 year olds must not be treated in the
                                       same group). Providers may bill for services only at times during
                                       which beneficiaries participate in group activities,
         90853         —               Group Outpatient – Group Psychotherapy
                                       Apply the above definition and requirements.
                                       Additional information: Use code 90853 with no modifier to claim
                                       for services provided to beneficiaries ages 21 and over.
         H2012         HA              SERVICE: Therapeutic Day/Acute Day Treatment
                                       DEFINITION: Short-term daily array of continuous, highly
                                       structured, intensive outpatient services provided by a mental
                                       health professional. These services are for beneficiaries
                                       experiencing acute psychiatric symptoms that may result in the
                                       beneficiary being in imminent danger of psychiatric hospitalization
                                       and are designed to stabilize the acute symptoms. These direct
                                       therapy and medical services are intended to be an alternative to
                                       inpatient psychiatric care and are expected to reasonably improve
                                       or maintain the beneficiary's condition and functional level to
                                       prevent hospitalization and assist with assimilation to his/her
                                       community after an inpatient psychiatric stay of any length. These
                                       services are to be provided by a team consisting of mental health
                                       clinicians, paraprofessionals and nurses, with physician oversight
                                       and availability. The team composition may vary depending on
                                       clinical and programmatic needs but must at a minimum include a
                                       licensed mental health clinician and physician who provide

                                                                                                     Section II-53
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                       services and oversight. Services are to be congruent with the age,
                                       strengths, needed accommodation for any disability, and cultural
                                       framework of the beneficiary and his/her family.
                                       These services must include constant staff supervision of
                                       beneficiaries and physician oversight.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 32
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11)
                                       STAFF to CLIENT RATIO: 1:5 for ages 18 and over; 1:4 for U18
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Start and stop times of actual program participation by
                                                beneficiary
                                               Place of service
                                               Diagnosis and pertinent interval history
                                               Brief mental status and observations
                                               Rationale for and interventions used that must coincide
                                                with the master treatment plan
                                               Beneficiary's response to the intervention must include
                                                current progress or lack of progress toward symptom
                                                reduction and attainment of goals
                                               Rationale for continued acute day service, including
                                                necessary changes to diagnosis, master treatment plan or
                                                medication(s) and plans to transition to less restrictive
                                                services
                                               Staff signature/credentials
                                       NOTES and COMMENTS: Providers may bill for services only at
                                       times during which beneficiaries participate in program activities.
                                       Providers are expected to sign beneficiaries in and out of the
                                       program to provide medically necessary treatment therapies.
                                       However, in order to be claimed separately, these therapies must
                                       be identified on the Master Treatment Plan and serve a treatment
                                       purpose which cannot be accomplished within the day treatment
                                       setting.
                                       See Section 219.110 for additional information.
         H2012         UA              Therapeutic Day/Acute Day Treatment
                                       Apply the above definition and requirements.
                                       Additional Information: Use code H2012 with modifier ―UA‖ to
                                       claim for services provided to beneficiaries ages 21 and over.
                                       See Section 219.110 for additional information.
         H2011         HA              SERVICE: Crisis Intervention
                                       DEFINITION: Unscheduled, immediate, short-term treatment
                                       activities provided to a Medicaid-eligible beneficiary who is
                                       experiencing a psychiatric or behavioral crisis. Services are to be
                                       congruent with the age, strengths, needed accommodation for any
                                       disability, and cultural framework of the beneficiary and his/her
                                       family. These services are designed to stabilize the person in
                                       crisis, prevent further deterioration, and provide immediate
                                       indicated treatment in the least restrictive setting. (These
                                       activities include evaluating a Medicaid-eligible beneficiary to
                                       determine if the need for crisis services is present.)

                                                                                                    Section II-54
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National      Required
         Code          Modifier        Definition
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 72
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); Nursing Facility (32); Skilled Nursing Facility (31);
                                       School (03); Homeless Shelter (04); Assisted Living Facility (13);
                                       Group Home (14); ICF/MR (54); Other Locations (99)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                              Date of Service
                                              Start and stop time of actual encounter with beneficiary
                                               and possible collateral contacts with caregivers or
                                               informed persons
                                              Place of service (If 99 is used, specific location and
                                               rationale for location must be included)
                                              Specific persons providing pertinent information in
                                               relationship to beneficiary
                                              Diagnosis and synopsis of events leading up to crisis
                                               situation
                                              Brief mental status and observations
                                              Utilization of previously established psychiatric advance
                                               directive or crisis plan as pertinent to current situation, OR
                                               rationale for crisis intervention activities utilized
                                              Beneficiary's response to the intervention that includes
                                               current progress or regression and prognosis
                                              Clear resolution of the current crisis and/or plans for
                                               further services
                                              Development of a clearly defined crisis plan or revision to
                                               existing plan
                                              Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: A psychiatric or behavioral crisis is
                                       defined as an acute situation in which an individual is
                                       experiencing a serious mental illness or emotional disturbance to
                                       the point that the beneficiary or others are at risk for imminent
                                       harm or in which to prevent significant deterioration of the
                                       beneficiary’s functioning.
         H2011         U7              Crisis Intervention
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2011 plus modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         Physician                     SERVICE: Physical Examination – Psychiatrist or Physician
         :
                       HA, UB          Physical Examination – Psychiatric Mental Health Clinical
         99201         HA, UB          Nurse Specialist or Psychiatric Mental Health Advanced
         99202         HA, UB          Nurse Practitioner
         99203         HA, UB
                                       DEFINITION: A general multisystem examination based on age
         99204         HA, UB
                                       and risk factors to determine the state of health of an enrolled
         99212         HA, UB
                                       RSPMI beneficiary.
         99213         HA, UB
         99214                         DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without

                                                                                                       Section II-55
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
         PCNS &                        extension: 12
         PANP:                         ALLOWABLE PLACES OF SERVICE: Office (11)
                       HA, SA          AGE GROUP(S): Ages 21 and over; U21
         99201
                       HA, SA          DOCUMENTATION REQUIREMENTS (See Section 226.200 for
         99202                         additional requirements):
                       HA, SA                  Start and stop times of actual encounter with beneficiary
         99203
                       HA, SA                  Date of service
         99204                                 Place of service
                       HA, SA                  Identifying information
         99212
                       HA, SA                  Referral reason and rationale for examination
         99213                                 Presenting problem(s)
                       HA, SA                  Health history
         99214
                                               Physical examination
                                               Laboratory and diagnostic procedures ordered
                                               Health education/counseling
                                               Identification of risk factors
                                               Mental status/clinical observations and impressions
                                               ICD-9 diagnoses
                                               DSM diagnostic impressions to include all five axes
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Treatment recommendations for findings, medications
                                                prescribed, and indicated informed consents
                                               Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: This service may be billed only by the
                                       RSPMI provider. The physician, Psychiatric Mental Health Clinical
                                       Nurse Specialist or Psychiatric Mental Health Advanced Nurse
                                       Practitioner may not bill for an office visit, nursing home visit, or
                                       any other outpatient medical services procedure for the
                                       beneficiary for the same date of service. Pharmacologic
                                       Management may not be billed on the same date of service as
                                       Physical Examination, as pharmacologic management would be
                                       considered one component of the full physical examination (office
                                       visit).
         90862         HA              SERVICE: Pharmacologic Management by Physician
                                       (formerly Medication Maintenance by a physician)
                                       Pharmacologic Management by Mental Health Clinical Nurse
                                       Specialist or Psychiatric Mental Health Advanced Nurse
                                       Practitioner
                                       DEFINITION: Provision of service tailored to reduce, stabilize or
                                       eliminate psychiatric symptoms by addressing individual goals in
                                       the master treatment plan. This service includes evaluation of the
                                       medication prescription, administration, monitoring, and
                                       supervision and informing beneficiaries regarding medication(s)
                                       and its potential effects and side effects in order to make informed
                                       decisions regarding the prescribed medications. Services must be
                                       congruent with the age, strengths, necessary accommodations for
                                       any disability, and cultural framework of the beneficiary and
                                       his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 2
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 24
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's

                                                                                                      Section II-56
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National      Required
         Code          Modifier        Definition
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Nursing Facility (32); Skilled
                                       Nursing Facility (31); ICF/MR (54)
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS(See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Start and stop times of actual encounter with beneficiary
                                               Place of service (If 99 is used for telemedicine, specific
                                                locations of the beneficiary and the physician must be
                                                included)
                                               Diagnosis and pertinent interval history
                                               Brief mental status and observations
                                               Rationale for and intervention used that must coincide with
                                                the master treatment plan
                                               Beneficiary's response to intervention that includes current
                                                progress or regression and prognosis
                                               Revisions indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for follow-up services, including any crisis plans
                                               If provided by physician that is not a psychiatrist, then any
                                                off label uses of medications should include documented
                                                consult with the overseeing psychiatrist within 24 hours of
                                                the prescription being written
                                               Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: Applies only to medications
                                       prescribed to address targeted symptoms as identified in the
                                       master treatment plan.
         90862         —               Pharmacologic Management by Physician
                                       Apply the above definition and requirements.
                                       Additional information: Use code 90862 with no modifier to claim
                                       for services provided to beneficiaries ages 21 and over.
         90862         U7              Pharmacologic Management by Physician
                                       Apply the above definition and requirements.
                                       Additional information: Use code 90862 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         90862         HA, UB          Pharmacologic Management by Psychiatric Mental Health
                                       Clinical Nurse Specialist or Psychiatric Mental Health
                                       Advanced Nurse Practitioner
                                       Apply the above definition and requirements.
         T1502         —               SERVICE: Medication Administration by a Licensed Nurse
                                       DEFINITION: Administration of a physician-prescribed medication
                                       to a beneficiary. This includes preparing the beneficiary and
                                       medication; actual administration of oral, intramuscular and/or
                                       subcutaneous medication; observation of the beneficiary after
                                       administration and any possible adverse reactions; and returning
                                       the medication to its previous storage.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED 1
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's

                                                                                                       Section II-57
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National      Required
         Code          Modifier        Definition
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Time of the specific procedure
                                               Place of service
                                               Physician’s order must be included in medication log
                                               Staff signature/credentials/date of signature
                                       NOTES and COMMENTS: Applies only to medications
                                       prescribed to address targeted symptoms as identified in the
                                       master treatment plan. Drugs and biologicals that can be self-
                                       administered shall not be in this group unless there is a
                                       documented reason the patient cannot self administer. Non-
                                       prescriptions and biologicals purchased by or dispensed to a
                                       patient are not covered.
         90862         HA, HQ          SERVICE: Group Outpatient – Pharmacologic Management
                                       by a Physician
                                       DEFINITION: Therapeutic intervention provided to a group of
                                       beneficiaries by a licensed physician involving evaluation and
                                       maintenance of the Medicaid-eligible beneficiary on a medication
                                       regimen with simultaneous supportive psychotherapy in a group
                                       setting. This includes evaluating medication prescription,
                                       administration, monitoring, and supervision; and informing
                                       beneficiaries regarding medication(s) and its potential effects and
                                       side effects. Services are to be congruent with the age, strengths,
                                       necessary accommodations for any disability, and cultural
                                       framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 6
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Homeless
                                       Shelter (04); Assisted Living Facility (13); Group Home (14)
                                       AGE GROUP(S): Ages 18 and over
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Start and stop times of actual group encounter that
                                                includes identified beneficiary
                                               Place of service
                                               Number of participants
                                               Diagnosis and pertinent interval history
                                               Focus of group
                                               Brief mental status and observations
                                               Rationale for group intervention and intervention used that
                                                must coincide with master treatment plan
                                               Beneficiary's response to the group intervention that
                                                includes current progress or regression and prognosis
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               If provided by physician that is not a psychiatrist, then any
                                                off label uses of medications must include documented
                                                consultation with the overseeing psychiatrist
                                               Plan for next group session, including any homework

                                                                                                       Section II-58
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                                assignments
                                               Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: This service applies only to
                                       medications prescribed to address targeted symptoms as
                                       identified in the master treatment plan. This does NOT include
                                       psychosocial groups in rehabilitative day programs or educational
                                       groups. The maximum that may be served in a specified group is
                                       ten (10). Providers may bill for services only at times during which
                                       beneficiaries participate in this program activity.
         36415         HA              SERVICE: Routine Venipuncture for Collection of Specimen
                                       DEFINITION: The process of drawing a blood sample through
                                       venipuncture (i.e., inserting a needle into a vein to draw the
                                       specimen with a syringe or vacutainer) or collecting a urine
                                       sample by catheterization as ordered by a physician or
                                       psychiatrist.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 1, Per
                                       routine
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 12
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Assisted
                                       Living Facility (13); Other Locations (99)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service
                                               Time of the specific procedure
                                               Place of service (If 99 is used, specific location and
                                                rationale for location must be included)
                                               Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: This service may be provided only to
                                       beneficiaries taking prescribed psychotropic medication or who
                                       have a substance abuse diagnosis.
         90887         HA              SERVICE: Collateral Intervention, Mental Health
                                       Professional
                                       DEFINITION: A face-to-face contact by a mental health
                                       professional with caregivers, family members, other community-
                                       based service providers or other Participants on behalf of and with
                                       the expressed written consent of an identified beneficiary in order
                                       to obtain or share relevant information necessary to the enrolled
                                       beneficiary's assessment, master treatment plan , and/or
                                       rehabilitation. The identified beneficiary does not have to be
                                       present for this service. Services are to be congruent with the
                                       age, strengths, needed accommodations for any disability, and
                                       cultural framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Patient's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of Service

                                                                                                      Section II-59
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                               Names and relationship to the beneficiary of all persons
                                                involved
                                               Start and stop times of actual encounter with collateral
                                                contact
                                               Place of Service (If 99 is used, specific location and
                                                rationale for location must be included)
                                               Client diagnosis necessitating intervention
                                               Document how interventions used address goals and
                                                objectives from the master treatment plan
                                               Information gained from collateral contact and how it
                                                relates to master treatment plan objectives
                                               Impact of information received/given on the beneficiary's
                                                treatment
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for next contact, if any
                                               Staff signature/credentials/Date of signature
                                       NOTES and COMMENTS: The collateral intervention must be
                                       identified on the master treatment plan as a medically necessary
                                       service. Medicaid WILL NOT pay for incidental or happenstance
                                       meetings with individuals. For example, a chance meeting with a
                                       beneficiary’s adult daughter at the corner store which results in a
                                       conversation regarding the well-being of the beneficiary may not
                                       be billed as a collateral contact.
                                       Billing for interventions performed by a mental health professional
                                       must warrant the need for the higher level of staff licensure.
                                       Professional interventions of a type which could be provided by a
                                       paraprofessional will require documentation of the reason it was
                                       needed.
                                       Contacts between individuals in the employment of RSPMI
                                       agencies or facilities are not a billable collateral intervention.
         90887         U7              Collateral Intervention, Mental Health Professional
                                       Apply the above definition and requirements.
                                       Additional information: Use code 90887 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         90887         HA, UB          SERVICE: Collateral Intervention, Mental Health
                                       Paraprofessional
                                       DEFINITION: A face-to-face contact by a mental health
                                       paraprofessional with caregivers, family members, other
                                       community-based service providers or other Participants on behalf
                                       of and with the expressed written consent of an identified
                                       beneficiary in order to obtain or share relevant information
                                       necessary to the enrolled beneficiary's assessment, master
                                       treatment plan, and/or rehabilitation. Services are to be congruent
                                       with the age, strengths, needed accommodation for any disability,
                                       and cultural framework of the beneficiary and his/her family. The
                                       identified beneficiary does not have to be present for this service.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 4
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Patient's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living

                                                                                                      Section II-60
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): Ages 21 and over; U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements:
                                               Date of Service
                                               Names and relationship to the beneficiary of all persons
                                                involved
                                               Start and stop times of actual encounter with collateral
                                                contact
                                               Place of Service (If 99 is used, specific location and
                                                rationale for location must be included)
                                               Client diagnosis necessitating intervention
                                               Document how interventions used address goals and
                                                objectives from the master treatment plan
                                               Information gained from collateral contact and how it
                                                relates to master treatment plan objectives
                                               Impact of information received/given on the beneficiary's
                                                treatment
                                               Any changes indicated for the master treatment plan
                                                which must be documented and communicated to the
                                                supervising MHP for consideration
                                               Plan for next contact, if any
                                               Staff signature/credentials/Date of signature
                                       NOTES and COMMENTS Supervision by a Mental Health
                                       Professional must be documented in personnel files and
                                       addressed in accordance of agency’s policies, quality assurance
                                       procedures, personnel performance evaluations, reports of
                                       supervisors, or other equivalent documented method of
                                       supervision.
                                       The collateral intervention must be identified on the master
                                       treatment plan as a medically necessary service. Medicaid WILL
                                       NOT pay for incidental or happenstance meetings with individuals.
                                       For example, a chance meeting with a beneficiary’s adult
                                       daughter at the corner store which results in a conversation
                                       regarding the well-being of the beneficiary may not be billed as a
                                       collateral contact. Contacts between individuals in the
                                       employment of RSPMI agencies or facilities are not a billable
                                       collateral intervention.
         H2011         HA, U6          SERVICE: Crisis Stabilization Intervention, Mental Health
                                       Professional
                                       DEFINITION: Scheduled face-to-face treatment activities
                                       provided to a beneficiary who has recently experienced a
                                       psychiatric or behavioral crisis that are expected to further
                                       stabilize, prevent deterioration, and serve as an alternative to 24-
                                       hour inpatient care. Services are to be congruent with the age,
                                       strengths, needed accommodation for any disability, and cultural
                                       framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 72
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): U21

                                                                                                     Section II-61
Rehabilitative Services for Persons with Mental Illness                                                   Section II

         National      Required
         Code          Modifier        Definition
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                              Date of service
                                              Start and stop time of actual encounter with beneficiary
                                              Place of service, (If 99 is used, specific location and
                                               rationale for location must be included)
                                              Diagnosis and pertinent interval history
                                              Brief mental status and observations
                                              Utilization of previously established psychiatric advance
                                               directive or crisis plan as pertinent to current situation, OR
                                               rationale for crisis intervention activities utilized
                                              Beneficiary's response to intervention that includes current
                                               progress or regression and prognosis
                                              Any changes indicated for the master treatment plan,
                                               diagnosis, or medication(s)
                                              Plan for next session, including any homework
                                               assignments
                                              Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: A psychiatric or behavioral crisis is
                                       defined as an acute situation in which an individual is
                                       experiencing a serious mental illness or emotional disturbance to
                                       the point that the beneficiary or others are at risk for imminent
                                       harm or in which to prevent significant deterioration of the
                                       beneficiary’s functioning.
         H2011         U2              Crisis Stabilization Intervention, Mental Health Professional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2011 with modifier ―U2‖ to
                                       claim for services provided to beneficiaries ages 21 and over.
         H2011         U2, U7          Crisis Stabilization Intervention, Mental Health Professional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2011 with modifier ―U2, U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         H2011         HA, U5          SERVICE: Crisis Stabilization Intervention, Mental Health
                                       Paraprofessional
                                       DEFINITION: Scheduled face-to-face treatment activities
                                       provided to a beneficiary who has recently experienced a
                                       psychiatric or behavioral crisis that are expected to further
                                       stabilize, prevent deterioration, and serve as an alternative to 24-
                                       hour inpatient care. Services are to be congruent with the age,
                                       strengths, needed accommodation for any disability, and cultural
                                       framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 12
                                       YEARLY MAXIMUM OF UNITS THAT MAY BE BILLED without
                                       extension: 72
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):

                                                                                                       Section II-62
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                              Date of service
                                              Start and stop time of actual encounter with beneficiary
                                              Place of service If 99 is used, specific location and
                                               rationale for location must be included)
                                              Diagnosis and pertinent interval history
                                              Behavioral observations
                                              Consult with MHP or physician regarding events that
                                               necessitated this service and the review of the outcome of
                                               the intervention
                                              Intervention used must coincide with the master treatment
                                               plan, psychiatric advance directive or crisis plan which
                                               must be documented and communicated to the
                                               supervising MHP
                                              Beneficiary's response to intervention that includes current
                                               progress or regression
                                              Plan for next session, including any homework
                                               assignments
                                              Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: A psychiatric or behavioral crisis is
                                       defined as an acute situation in which an individual is
                                       experiencing a serious mental illness or emotional disturbance to
                                       the point that the beneficiary or others are at risk for imminent
                                       harm or in which to prevent significant deterioration of the
                                       beneficiary’s functioning.
                                       Supervision by a Mental Health Professional must be documented
                                       and addressed in personnel files in accordance with the agency’s
                                       policies, quality assurance procedures, personnel performance
                                       evaluations, reports of supervisors, or other equivalent
                                       documented method of supervision.
         H2011         U1              Crisis Stabilization Intervention, Mental Health
                                       Paraprofessional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2011 with modifier ―U1‖ to
                                       claim for services provided to beneficiaries ages 21 and over
         H2015         HA, U5          SERVICE: Intervention, Mental Health Professional (formerly
                                       On-Site and Off-Site Interventions, MHP)
                                       DEFINITION: Face-to-face medically necessary treatment
                                       activities provided to a beneficiary consisting of specific
                                       therapeutic interventions as prescribed on the master treatment
                                       plan to re-direct a beneficiary from a psychiatric or behavioral
                                       regression or to improve the beneficiary’s progress toward
                                       specific goal(s) and outcomes. These activities may be either
                                       scheduled or unscheduled as the goal warrants. Services are to
                                       be congruent with the age, strengths, necessary accommodations
                                       for any disability, and cultural framework of the beneficiary and
                                       his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for

                                                                                                     Section II-63
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       additional requirements):
                                               Start and stop times of actual encounter with beneficiary
                                               Date of service
                                               Place of service, (If 99 is used, specific location and
                                                rationale for location must be included)
                                               Client diagnosis necessitating intervention
                                               Brief mental status and observations
                                               Document how interventions used address goals and
                                                objectives from the master treatment plan
                                               Beneficiary's response to intervention that includes current
                                                progress or regression and prognosis
                                               Any changes indicated for the master treatment plan,
                                                diagnosis, or medication(s)
                                               Plan for next intervention, including any homework
                                                assignments
                                               Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: Interventions of a type that could be
                                       performed by a paraprofessional may not be billed at a mental
                                       health professional rate unless the medical necessity for higher
                                       level staff is clearly documented.
         H2015         U6              Intervention, Mental Health Professional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2015 with modifier ―U6‖ to
                                       claim for services provided to beneficiaries ages 21 and over.
         H2015         U7              Intervention, Mental Health Professional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2015 with modifier ―U7‖ to
                                       claim for services provided via telemedicine only. Note:
                                       Telemedicine POS 99
         H2015         HA, U1          SERVICE: Intervention, Mental Health Paraprofessional
                                       (formerly On-Site and Off-Site Intervention, Mental Health
                                       Paraprofessional)
                                       DEFINITION: Face-to-face, medically necessary treatment
                                       activities provided to a beneficiary consisting of specific
                                       therapeutic interventions prescribed on the master treatment plan,
                                       which are expected to accomplish a specific goal or objective
                                       listed on the master treatment plan. These activities may be
                                       either scheduled or unscheduled as the goal or objective
                                       warrants. Services are to be congruent with the age, strengths,
                                       necessary accommodations for any disability, and cultural
                                       framework of the beneficiary and his/her family.
                                       DAILY MAXIMUM OF UNITS THAT MAY BE BILLED: 8
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Beneficiary's
                                       Home (12); School (03); Homeless Shelter (04); Assisted Living
                                       Facility (13); Group Home (14); Other Locations (99)
                                       AGE GROUP(S): U21
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of service
                                               Start and stop times of actual encounter with beneficiary

                                                                                                      Section II-64
Rehabilitative Services for Persons with Mental Illness                                                 Section II

         National      Required
         Code          Modifier        Definition
                                              Place of service (If 99 is used, specific location and
                                               rationale for location must be included)
                                              Client diagnosis necessitating intervention
                                              Document how interventions used address goals and
                                               objectives from the master treatment plan
                                              Beneficiary's response to intervention that includes current
                                               progress or regression and prognosis
                                              Plan for next intervention, including any homework
                                               assignments
                                              Staff signature/credentials/date of signature(s)
                                       NOTES and COMMENTS: Billing for this service does not
                                       include time spent transporting the beneficiary to a required
                                       service, nor does it include time spent waiting while a beneficiary
                                       attends a scheduled or unscheduled appointment. Supervision by
                                       a Mental Health Professional must be documented and addressed
                                       in personnel files in accordance with the agency’s policies, quality
                                       assurance procedures, personnel performance evaluations,
                                       reports of supervisors, or other equivalent documented method of
                                       supervision.
         H2015         U2              Intervention, Mental Health Paraprofessional
                                       Apply the above definition and requirements.
                                       Additional information: Use code H2015 with modifier ―U2‖ to
                                       claim for services provided to beneficiaries ages 21 and over
         H2017         HA, U1          SERVICE: Rehabilitative Day Service for Persons under Age
                                       18
                                       DEFINITION: An array of face-to-face interventions providing a
                                       preplanned and structured group program for identified
                                       beneficiaries that improve emotional and behavioral symptoms of
                                       youth diagnosed with childhood disorders, as distinguished from
                                       the symptom stabilization function of acute day treatment. These
                                       interventions are person- and family-centered, age-appropriate,
                                       recovery based, culturally competent, must reasonably
                                       accommodate disability, and must have measurable outcomes.
                                       These activities are designed to assist the beneficiary with
                                       compensating for or eliminating functional deficits and
                                       interpersonal and/or environmental barriers associated with their
                                       mental illness. The intent of these services is to enhance a
                                       youth's functioning in the home, school, and community with the
                                       least amount of ongoing professional intervention. Skills
                                       addressed may include: emotional skills, such as coping with
                                       stress, anxiety, or anger; behavioral skills, such as positive peer
                                       interactions, appropriate social/family interactions, and managing
                                       overt expression of symptoms like impulsivity and anger; daily
                                       living and self-care skills, such as personal care and hygiene, and
                                       daily structure/use of time; cognitive skills, such as problem
                                       solving, developing a positive self-esteem, and reframing, money
                                       management, community integration, understanding illness,
                                       symptoms and the proper use of medications; and any similar
                                       skills required to implement a beneficiary's master treatment plan .
                                       DAILY MAXIMUM UNITS THAT MAY BE BILLED: 16 for ages
                                       0-17
                                       WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 80 for
                                       ages 0-17

                                                                                                     Section II-65
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); School (03);
                                       Assisted Living Facility (13); Group Home (14); Other Locations
                                       (99) (churches, community centers, space donated solely for
                                       clinical services, and appropriate community locations tied to the
                                       beneficiary’s treatment plan).
                                       MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS:
                                       1:10 ratio maximum with the provision that client ratio must be
                                       reduced when necessary to accommodate significant issues
                                       related to acuity, developmental status and clinical needs.
                                       AGE GROUP(S): U18
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Start and stop times of actual program participation by
                                                beneficiary
                                               Date of service
                                               Place of service
                                               Client diagnosis necessitating intervention
                                               Behavioral observations
                                               Document how interventions used address goals and
                                                objectives from the master treatment plan
                                               Beneficiary's participation and response to the intervention
                                               Staff signature/credentials
                                               Supervising staff signature/credentials/date of signature(s)
                                               a weekly summary describing therapeutic activities
                                                provided and the beneficiary's progress or lack of
                                                progress in achieving the treatment goal(s) and
                                                established outcomes to be accomplished
                                       NOTES and COMMENTS: Providers may bill for services only at
                                       times during which beneficiaries participate in program activities.
                                       Providers are expected to sign beneficiaries in and out of the
                                       program to provide medically necessary treatment therapies.
                                       However, in order to be claimed separately, these therapies must
                                       be identified on the Master Treatment Plan and serve a treatment
                                       purpose which cannot be accomplished within the day treatment
                                       setting.
         H2017         —               Rehabilitative Day Service for Persons Ages 18-20
                                       Apply the above definition and requirements (except Staff to
                                       Client Ratios, which are outlined below).
                                       Additional information: Use code H2017 with no modifier to claim
                                       for services provided to beneficiaries for ages 18-20.
                                       DAILY MAXIMUM UNITS THAT MAY BE BILLED: 24
                                       WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 120
                                       MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS:
                                       1:15 ratio maximum with the provision that client ratio must be
                                       reduced when necessary to accommodate significant issues
                                       related to acuity, developmental status and clinical needs.
         H2017         —               SERVICE: Adult Rehabilitative Day Service
                                       DEFINITION: An array of face-to-face interventions providing a
                                       preplanned and structured group program for identified
                                       beneficiaries that aimed at long-term recovery and maximization

                                                                                                      Section II-66
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         National      Required
         Code          Modifier        Definition
                                       of self-sufficiency, as distinguished from the symptom stabilization
                                       function of acute day treatment. These interventions are person-
                                       and family-centered, recovery based, culturally competent,
                                       provide needed accommodation for any disability and must have
                                       measurable outcomes. These activities assist the beneficiary with
                                       compensating for or eliminating functional deficits and
                                       interpersonal and/or environmental barriers associated with their
                                       chronic mental illness. The intent of these services is to restore
                                       the fullest possible integration of the beneficiary as an active and
                                       productive member of his/her family, social and work community
                                       and/or culture with the least amount of ongoing professional
                                       intervention. Skills addressed may include: emotional skills, such
                                       as coping with stress, anxiety, or anger; behavioral skills, such as
                                       proper use of medications, appropriate social interactions, and
                                       managing overt expression of symptoms like delusions or
                                       hallucinations; daily living and self-care skills, such as personal
                                       care and hygiene, money management, and daily structure/use of
                                       time; cognitive skills, such as problem solving, understanding
                                       illness and symptoms, and reframing; community integration skills
                                       and any similar skills required to implement a beneficiary's master
                                       treatment plan .
                                       DAILY MAXIMUM UNITS THAT MAY BE BILLED: 24
                                       WEEKLY MAXIMUM OF UNITS THAT MAY BE BILLED: 120
                                       PRIOR AUTHORIZATION REQUIRED
                                       ALLOWABLE PLACES OF SERVICE: Office (11); Assisted
                                       Living Facility (13); Group Home (14); Other Locations (99)
                                       (churches, community centers, space donated solely for clinical
                                       services, and appropriate community locations tied to the
                                       beneficiary’s treatment plan).
                                       MAXIMUM PARAPROFESSIONAL STAFF to CLIENT RATIOS:
                                       1:15 ratio maximum with the provision that client ratio must be
                                       reduced when necessary to accommodate significant issues
                                       related to acuity, developmental status and clinical needs.
                                       AGE GROUP(S): Ages 21 and over
                                       DOCUMENTATION REQUIREMENTS (See Section 226.200 for
                                       additional requirements):
                                               Date of service
                                               Start and stop times of actual program participation by
                                                beneficiary
                                               Place of service
                                               Client diagnosis necessitating intervention
                                               Behavioral observations
                                               Document how interventions used address goals and
                                                objectives from the master treatment plan
                                               Beneficiary's participation and response to the intervention
                                               Staff signature/credentials
                                               Supervising staff signature/credentials/date of signature(s)
                                               A weekly summary describing therapeutic activities
                                                provided and the beneficiary's progress or lack of
                                                progress in achieving the treatment goal(s) and
                                                established outcomes to be accomplished through
                                                participation in rehabilitative day service.
                                       NOTES and COMMENTS: Rehabilitative Day services do NOT
                                       include vocational services and training, academic education,
                                       personal care or home health services, purely recreational

                                                                                                      Section II-67
Rehabilitative Services for Persons with Mental Illness                                                    Section II

         National      Required
         Code          Modifier        Definition
                                       activities and may NOT be used to supplant services which may
                                       be obtained or are required to be provided by other means.
                                       Providers may bill for services only at times during which
                                       beneficiaries participate in program activities. Providers are
                                       expected to sign beneficiaries in and out of the program to provide
                                       medically necessary treatment therapies. However, in order to be
                                       claimed separately, these therapies must be identified on the
                                       Master Treatment Plan and serve a treatment purpose which
                                       cannot be accomplished within the day treatment setting.


    252.130          Inpatient Hospital Procedure Codes                                                 7-1-07

        RSPMI providers may be reimbursed for the following visits made to patients of acute care
        inpatient hospitals by board-certified or board eligible psychiatrists.

         99218                 99219               99220             99221               99222
         99223                 99231               99232             99233               99234
         99235                 99236               99238             99251               99252
         99253                 99254               99255


    252.140          Telemedicine RSPMI Services Billing Information                                   10-5-09

        The mental health professional may provide certain treatment services from a remote site to the
        Medicaid-eligible beneficiary age 21 or over who is located in a mental health clinic setting. See
        Section 252.410 for billing instructions.
        The following services may be provided via telemedicine by a mental health professional, bill
        with POS 99:

         National         Required         Local Code      Local Code Description
         Code             Modifier
         90801            U7               Z0560           Mental Health Evaluation/Diagnosis
         90887            U3, U7           Z0564           Interpretation of Diagnosis
         H0004            U7               Z0568           Individual Psychotherapy
         90846            U7               Z0571           Marital/Family Psychotherapy – Beneficiary is
                                                           not present
         90847            U7                               Marital/Family Psychotherapy – Beneficiary is
                                                           present
         H2011            U7               Z1536           Crisis Intervention
         T1023            U7               Z1537           Psychiatric Diagnostic Assessment
         H2011            U2, U7                           Crisis Stabilization Intervention, Mental
                                                           Health Professional
         H2015            U7               Z1540           Intervention, Mental Health Professional
         90862            U7               Z1545           Pharmacologic Management by a Physician
         90887            U7               Z1547           Collateral Intervention, Mental Health

                                                                                                        Section II-68
Rehabilitative Services for Persons with Mental Illness                                              Section II

         National         Required         Local Code        Local Code Description
         Code             Modifier
                                                             Professional


    252.150          Services Available to Residents of Long Term Care Facilities Billing        10-5-09
                     Information

        The following RSPMI procedure codes are payable to an RSPMI provider for services provided
        to residents of nursing homes who are Medicaid eligible when prescribed according to policy
        guidelines detailed in this manual:

         National       Required      Local Code      Local Code Description
         Code           Modifier
         90801          U1            Z0560           Mental Health Evaluation/Diagnosis
         90885          HA, U2                        Master Treatment Plan
         90885          HA                            Periodic Review of Master Treatment Plan
         90885          HA, U1                        Periodic Review of Master Treatment Plan
         90887          U2            Z0564           Interpretation of Diagnosis
         H0004          —             Z0568           Individual Psychotherapy
         H2011          U7            Z1536           Crisis Intervention


        Services provided to nursing home residents may be provided on or off site from the RSPMI
        provider. The services may be provided in the long-term care (LTC) facility, if necessary.

    252.200          Place of Service Codes                                                      10-4-09

        Electronic and paper claims now require the same national place of service codes.

         Place of Service                                    POS Codes
         Outpatient Hospital                                 22
         Office (RSPMI Facility Service Site)                11
         Patient’s Home                                      12
         Nursing Facility                                    32
         Skilled Nursing Facility                            31
         School (Including Licensed Child Care               03
         Facility)
         Homeless Shelter                                    04
         Assisted Living Facility (Including Residential     13
         Care Facility)
         Group Home                                          14
         ICF/MR                                              54
         Other Locations                                     99
         RSPMI Clinic (Telemedicine)                         99


                                                                                                  Section II-69
Rehabilitative Services for Persons with Mental Illness                                                        Section II

         Place of Service                                    POS Codes
         Emergency Services in ER                            23


    252.300           Billing Instructions - Paper Only                                                   7-1-07

        HP Enterprise Services offers providers several options for electronic billing. Therefore, claims
        submitted on paper are paid once a month. The only claims exempt from this process are those
        that require attachments or manual pricing.
        To bill for RSPMI services, use the CMS-1500 form The numbered items correspond to
        numbered fields on the claim form. View a CMS-1500 sample form.
        When completing the CMS-1500, accuracy, completeness and clarity are important. Claims
        cannot be processed if applicable information is not supplied or is illegible. Claims should be
        typed whenever possible.
        Completed claim forms should be forwarded to HP Enterprise Services. View or print HP
        Enterprise Services Claims contact information.

        NOTE: A provider rendering services without verifying eligibility for each date of service
              does so at the risk of not being reimbursed for the services.

     252.310           Completion of the CMS-1500 Claim Form                                                11-1-08


         Field Name and Number                      Instructions for Completion
         1.    (type of coverage)                   Not required.
         1a. INSURED’S I.D. NUMBER                  Beneficiary’s or participant’s 10-digit Medicaid or
             (For Program in Item 1)                ARKids First-A or ARKids First-B identification
                                                    number.
         2.    PATIENT’S NAME (Last                 Beneficiary’s or participant’s last name and first
               Name, First Name, Middle             name.
               Initial)
         3.    PATIENT’S BIRTH DATE                 Beneficiary’s or participant’s date of birth as given on
                                                    the individual’s Medicaid or ARKids First-A or ARKids
                                                    First-B identification card. Format: MM/DD/YY.
               SEX                                  Check M for male or F for female.
         4.    INSURED’S NAME (Last                 Required if insurance affects this claim. Insured’s last
               Name, First Name, Middle             name, first name, and middle initial.
               Initial)
         5.    PATIENT’S ADDRESS (No.,              Optional. Beneficiary’s or participant’s complete
               Street)                              mailing address (street address or post office box).
               CITY                                 Name of the city in which the beneficiary or
                                                    participant resides.
               STATE                                Two-letter postal code for the state in which the
                                                    beneficiary or participant resides.
               ZIP CODE                             Five-digit zip code; nine digits for post office box.
               TELEPHONE (Include Area              The beneficiary’s or participant’s telephone number
               Code)                                or the number of a reliable message/contact/
                                                    emergency telephone


                                                                                                            Section II-70
Rehabilitative Services for Persons with Mental Illness                                                     Section II

         Field Name and Number                      Instructions for Completion
         6.    PATIENT RELATIONSHIP TO              If insurance affects this claim, check the box
               INSURED                              indicating the patient’s relationship to the insured.
         7.    INSURED’S ADDRESS (No.,              Required if insured’s address is different from the
               Street)                              patient’s address.
               CITY
               STATE
               ZIP CODE
               TELEPHONE (Include Area
               Code)
         8.    PATIENT STATUS                       Not required.

         9.    OTHER INSURED’S NAME                 If patient has other insurance coverage as indicated
               (Last name, First Name,              in Field 11d, the other insured’s last name, first name,
               Middle Initial)                      and middle initial.

               a.     OTHER INSURED’S               Policy and/or group number of the insured individual.
                      POLICY OR GROUP
                      NUMBER
               b.     OTHER INSURED’S               Not required.
                      DATE OF BIRTH
                      SEX                           Not required.
               c.     EMPLOYER’S NAME OR            Required when items 9 a-d are required. Name of the
                      SCHOOL NAME                   insured individual’s employer and/or school.
               d.     INSURANCE PLAN                Name of the insurance company.
                      NAME OR PROGRAM
                      NAME
         10. IS PATIENT’S CONDITION
             RELATED TO:
               a.     EMPLOYMENT? (Current          Check YES or NO.
                      or Previous)
               b.     AUTO ACCIDENT?                Required when an auto accident is related to the
                                                    services. Check YES or NO.
                      PLACE (State)                 If 10b is YES, the two-letter postal abbreviation for
                                                    the state in which the automobile accident took place.
               c.     OTHER ACCIDENT?               Required when an accident other than automobile is
                                                    related to the services. Check YES or NO.
               10d. RESERVED FOR LOCAL              Not used.
                    USE
         11. INSURED’S POLICY GROUP                 Not required when Medicaid is the only payer.
             OR FECA NUMBER
               a.     INSURED’S DATE OF             Not required.
                      BIRTH
                      SEX                           Not required.
               b.     EMPLOYER’S NAME OR            Not required.
                      SCHOOL NAME


                                                                                                        Section II-71
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         Field Name and Number                      Instructions for Completion
               c.    INSURANCE PLAN                 Not required.
                     NAME OR PROGRAM
                     NAME
               d.    IS THERE ANOTHER               When private or other insurance may or will cover
                     HEALTH BENEFIT                 any of the services, check YES and complete items
                     PLAN?                          9a through 9d.
         12. PATIENT’S OR AUTHORIZED                Not required.
             PERSON’S SIGNATURE
         13. INSURED’S OR                           Not required.
             AUTHORIZED PERSON’S
             SIGNATURE
         14. DATE OF CURRENT:                       Required when services furnished are related to an
                                                    accident, whether the accident is recent or in the
               ILLNESS (First symptom) OR
                                                    past. Date of the accident.
               INJURY (Accident) OR
               PREGNANCY (LMP)
         15. IF PATIENT HAS HAD SAME                Not required.
             OR SIMILAR ILLNESS, GIVE
             FIRST DATE
         16. DATES PATIENT UNABLE TO                Not required.
             WORK IN CURRENT
             OCCUPATION
         17. NAME OF REFERRING                      Primary Care Physician (PCP) referral is required for
             PROVIDER OR OTHER                      RSPMI services for individuals under age 21. If
             SOURCE                                 services are the result of a Child Health Services
                                                    (EPSDT) screening/ referral, enter the referral
                                                    source, including name and title.
         17a. (blank)                               The 9-digit Arkansas Medicaid provider ID number of
                                                    the referring physician.
         17b. NPI                                   Not required.
         18. HOSPITALIZATION DATES                  When the serving/billing provider’s services charged
             RELATED TO CURRENT                     on this claim are related to a beneficiary’s or
             SERVICES                               participant’s inpatient hospitalization, enter the
                                                    individual’s admission and discharge dates. Format:
                                                    MM/DD/YY.
         19.   RESERVED FOR LOCAL                   Not applicable to RSPMI.
               USE
         20. OUTSIDE LAB?                           Not required.
               $ CHARGES                            Not required.
         21. DIAGNOSIS OR NATURE OF                 Diagnosis code for the primary medical condition for
             ILLNESS OR INJURY                      which services are being billed. Up to three additional
                                                    diagnosis codes can be listed in this field for
                                                    information or documentation purposes. Use the
                                                    International Classification of Diseases, Ninth
                                                    Revision Clinical Modification (ICD-9-CM) diagnosis
                                                    coding, current as of the date of service.
         22. MEDICAID RESUBMISSION                  Reserved for future use.
             CODE

                                                                                                      Section II-72
Rehabilitative Services for Persons with Mental Illness                                                    Section II

         Field Name and Number                      Instructions for Completion
                ORIGINAL REF. NO.                   Reserved for future use.
         23. PRIOR AUTHORIZATION                    The prior authorization or benefit extension control
             NUMBER                                 number if applicable.
         24A.        DATE(S) OF SERVICE             The ―from‖ and ―to‖ dates of service for each billed
                                                    service. Format: MM/DD/YY.
                                                    1. On a single claim detail (one charge on one line),
                                                       bill only for services provided within a single
                                                       calendar month.
                                                    2. Providers may bill on the same claim detail for
                                                       two or more sequential dates of service within the
                                                       same calendar month when the provider
                                                       furnished equal amounts of the service on each
                                                       day of the date sequence.
                B.   PLACE OF SERVICE               Two-digit national standard place of service code.
                                                    See Section 252.200 for codes.
                C.   EMG                            Not required.
                D.   PROCEDURES,
                     SERVICES, OR
                     SUPPLIES
                     CPT/HCPCS                      Enter the correct CPT or HCPCS procedure codes
                                                    from Sections 252.100 through 252.150.
                     MODIFIER                       Use applicable modifier.
                E.   DIAGNOSIS POINTER              Enter in each detail the single number—1, 2, 3, or
                                                    4—that corresponds to a diagnosis code in Item 21
                                                    (numbered 1, 2, 3, or 4) and that supports most
                                                    definitively the medical necessity of the service(s)
                                                    identified and charged in that detail. Enter only one
                                                    number in E of each detail. Each DIAGNOSIS
                                                    POINTER number must be only a 1, 2, 3, or 4, and it
                                                    must be the only character in that field.
                F.   $ CHARGES                      The full charge for the service(s) totaled in the detail.
                                                    This charge must be the usual charge to any client,
                                                    patient, or other beneficiary of the provider’s services.
                G.   DAYS OR UNITS                  The units (in whole numbers) of service(s) provided
                                                    during the period indicated in Field 24A of the detail. .
                H.   EPSDT/Family Plan              Enter E if the services resulted from a Child Health
                                                    Services (EPSDT) screening/referral.
                I.   ID QUAL                        Not required.
                J.   RENDERING PROVIDER             The 9-digit Arkansas Medicaid provider ID number of
                     ID #                           the individual who furnished the services billed for in
                                                    the detail.
                     NPI                            Not required.
         25. FEDERAL TAX I.D. NUMBER                Not required. This information is carried in the
                                                    provider’s Medicaid file. If it changes, please contact
                                                    Provider Enrollment.



                                                                                                        Section II-73
Rehabilitative Services for Persons with Mental Illness                                                  Section II

         Field Name and Number                      Instructions for Completion
         26. PATIENT’S ACCOUNT NO.                  Optional entry that may be used for accounting
                                                    purposes; use up to 16 numeric or alphabetic
                                                    characters. This number appears on the Remittance
                                                    Advice as ―MRN.‖
         27. ACCEPT ASSIGNMENT?                     Not required. Assignment is automatically accepted
                                                    by the provider when billing Medicaid.
         28. TOTAL CHARGE                           Total of Column 24F—the sum all charges on the
                                                    claim.
         29. AMOUNT PAID                            Enter the total of payments previously received on
                                                    this claim. Do not include amounts previously paid by
                                                    Medicaid. Do not include in this total the
                                                    automatically deducted Medicaid or ARKids First-B
                                                    co-payments.
         30. BALANCE DUE                            From the total charge, subtract amounts received
                                                    from other sources and enter the result.
         31. SIGNATURE OF PHYSICIAN                 The provider or designated authorized individual must
             OR SUPPLIER INCLUDING                  sign and date the claim certifying that the services
             DEGREES OR                             were personally rendered by the provider or under
             CREDENTIALS                            the provider’s direction. ―Provider’s signature‖ is
                                                    defined as the provider’s actual signature, a rubber
                                                    stamp of the provider’s signature, an automated
                                                    signature, a typewritten signature, or the signature of
                                                    an individual authorized by the provider rendering the
                                                    service. The name of a clinic or group is not
                                                    acceptable.
         32. SERVICE FACILITY                       Enter the name and street, city, state, and zip code of
             LOCATION INFORMATION                   the facility where services were performed.
               a. (blank)                           Not required.
               b. Service Site Medicaid ID          Enter the 9-digit Arkansas Medicaid provider ID
               number                               number of the service site.
         33. BILLING PROVIDER INFO &                Billing provider’s name and complete address.
             PH #                                   Telephone number is requested but not required.
               a. (blank)                           Not required.
               b. (blank)                           Enter the 9-digit Arkansas Medicaid provider ID
                                                    number of the billing provider.


    252.400          Special Billing Procedures

    252.410          RSPMI Billing Instructions                                                       7-1-07

        RSPMI Medicaid providers who provide covered telemedicine services must comply with the
        definitions and coding requirements outlined below when billing Medicaid.
              1.     Telemedicine transactions involve interaction between a mental health professional
                     and a beneficiary who are in different locations. The beneficiary must be in a mental
                     health clinic setting.
                     Telemedicine Site Definitions
                            Local Site:       The local site is the patient’s location.

                                                                                                      Section II-74
Rehabilitative Services for Persons with Mental Illness                                                   Section II

                           Remote Site:       The remote site is the location of the mental health
                                              professional performing a telemedicine service for the
                                              beneficiary at the local site.
              2.     The place of service code is determined by the patient’s location (the local site). The
                     remote site is never the place of service.
                     Telemedicine Place of Service Codes
                           Paper Claims Code = H, Electronic Claims Code = 99 RSPMI Clinic
                               (Telemedicine)

    252.420          Non-Covered Diagnosis Codes                                                       8-1-05

        RSPMI services are not covered by Arkansas Medicaid for an individual of any age whose
        primary diagnosis is substance abuse. A claim filed for any RSPMI service will be denied if
        the primary diagnosis code is listed below.

         291.0                      292.84                  304.40                  305.50
         291.4                      292.89                  304.50                  305.60
         291.8                      292.9                   304.60                  305.70
         292.0                      303.00                  304.90                  305.90
         292.11                     303.90                  305.00                  317
         292.12                     304.00                  305.10                  318.0
         292.81                     304.10                  305.20                  318.1
         292.82                     304.20                  305.30                  318.2
         292.83                     304.30                  305.40                  319


        For an RSPMI provider delivering an RSPMI service, the primary diagnosis is the DSM-IV mental
        health disorder that is the primary focus of the mental health treatment service being delivered.

        For persons being treated by an RSPMI provider for a mental health disorder who also have a
        co-occurring substance use disorder(s), this (these) substance use disorder(s) is (are) listed as a
        secondary diagnosis. Treatment plans should clearly reflect any services that may be needed to
        address the co-occurring substance use problems, whether offered by the RSPMI provider or via
        a referral to another provider. RSPMI providers that are also substance abuse treatment
        providers may also provide substance abuse treatment services to their mental health clients.
        These substance abuse treatment services are not billable as an RSPMI service. In the
        provision of RSPMI mental health services, the substance use disorder is appropriately focused
        on with the client in terms of its impact on and relationship to the primary mental health disorder.
        All RSPMI services must be focused toward and address the mental health needs of the client.
        Substance use issues should be addressed and documented within the context of the impact of
        the substance use disorder on the mental health disorder that is the focus of the RSPMI service
        being delivered.

    252.430          Daily Service Billing Exclusions                                              10-4-09

        RSPMI providers may not bill for the following services together on the same date of service:

         National Codes and             Service Titles
         Modifiers



                                                                                                       Section II-75
Rehabilitative Services for Persons with Mental Illness                                             Section II

         National Codes and             Service Titles
         Modifiers
         90885 -HA, U2                  Master treatment plan and Periodic Review of Master treatment
         AND                            plan
         90885 – HA or
         90885 – HA, U1
         H2017-HA, U1                   Adult Rehabilitative Day Service
         AND                            AND
         H2017                          U21 Rehabilitative Day Service
         90801 or 90801-HA, U1          Mental Health Evaluation/Diagnosis
         AND                            AND
         90885-HA, or 90885 HA,         Periodic Review of Master treatment plan
         U1
         90862 or 90862-HA or           Pharmacologic Management
         90862-HA,UB
         AND                            AND
         90862-HA, HQ                   Group Outpatient – Pharmacologic Management by a Physician
         H2012 – HA or H2012 –          *Therapeutic Day/Acute Day
         UA
         AND                            AND
         H2017                          Adult Rehabilitative Day Service
         H2012 – HA or H2012 –          *Therapeutic Day/Acute Day
         UA
         AND                            AND
         H2017 – HA, U1                 U21 Rehabilitative Day Service
         99201-HA,UB; 99202-            Physical Examination
         HA, UB; 99203-HA, UB;
         99204-HA, UB; 99211-
         HA, UB; 99212 – HA, UB;
         99213 – HA, UB; 99214–
         HA,UB; 99201-HA,SA;
         99202-HA, SA; 99203-
         HA, SA; 99204-HA, SA;
         99211-HA, SA; 99212 –
         HA, SA; 99213 – HA, SA;
         99214 – HA, SA;
         AND                            AND
         90862 or 90862-HA or           Pharmacologic Management
         90862-HA,UB
         99201-HA,UB; 99202-            Physical Examination
         HA, UB; 99203-HA, UB;
         99204-HA, UB; 99211-
         HA, UB; 99212 – HA, UB;
         99213 – HA, UB; 99214–
         HA,UB; 99201-HA,SA;
         99202-HA, SA; 99203-
         HA, SA; 99204-HA, SA;
         99211-HA, SA; 99212 –
         HA, SA; 99213 – HA, SA;
         99214 – HA, SA;
         AND                            AND
         90862-HA, HQ                   Group Outpatient – Pharmacologic Management by a Physician


                                                                                                 Section II-76

				
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