Current through Reg. 50, No. 187; September 24, 2024
(1) Treatment Plan. A written treatment plan
shall be developed within 10 working days of enrollment into the Behavioral
Health Network for each enrolled child. At a minimum, the plan shall include
clear time-limited treatment objectives, related interventions, clinical
criteria for discharge, and evidence that the child and family, consistent with
the statutes and rules of the department for family involvement, has been
included in the development of the treatment plan.
(a) A board certified child psychiatrist or a
Licensed Practitioner of the Healing Arts with experience treating children who
have mental or substance-related disorders shall serve as the authorizing
authority for necessary services. The Lead Agency shall communicate the details
of the plan to the local Children's Medical Services Area Office. The plan
shall be reviewed and updated no later than ninety (90) days apart.
(b) Notwithstanding paragraph
65E-11.007(1)(a),
F.A.C., above, if the provider can demonstrate that a board certified child
psychiatrist or a Licensed Practitioner of the Healing Arts with experience
treating children who have mental or substance-related disorders is not
available for participation due to the lack of availability, a psychiatrist
with experience treating children who have mental disorders or a medical doctor
with experience treating children for substance-related disorders shall serve
as the authorizing authority for necessary services.
(2) Behavioral health services financed
through the Behavioral Health Network shall not begin until after the child's
enrollment as defined in Rule
65E-11.003, F.A.C.
(3) Written Policies and Procedures. The
department shall not enter into any contract with a Provider of Behavioral
Health Services unless the provider has developed written policies and
procedures to comply with the requirements of this rule.
(4) Written policies and procedures shall be
approved by the department prior to implementation of said policies and
procedures and shall be based on the standards described in Rule
65E-11.005, F.A.C., for treating
behavioral health disorders and shall additionally address the following:
(a) The operation of the utilization
management program;
(b) An annual
review by a quality improvement committee;
(c) Documentation required for specific
service approvals and denials, along with the timeframes for communicating
decisions to the appropriate Behavioral Health Services provider;
(d) Collection of data to review the criteria
and process used to evaluate services for medical necessity as described in
subsection 65E-11.002(18),
F.A.C.;
(e) Collection of data
measuring lengths of stay, utilization of services, and the procedures to be
followed when the data indicates patterns of deviation from the norm;
(f) The review of procedures to be used in
formulating recommendations for admission, discharge, and disenrollment
consistent with subsections
65E-11.005(2)
and 65E-11.007(4),
F.A.C.;
(g) The review of client
service utilization data in the aggregate, with a targeted focus on high users
and low users of service as compared to the norm. Such client service data
shall minimally include length of service by treatment modality, office visits,
days per intake, and the penetration and length of stay in intensive outpatient
and acute inpatient services;
(h)
Procedures to ensure that a professional described in Chapter 397, 490, or 491,
F.S., and who also has 5 years experience in the diagnosis and treatment of
children with mental or substance-related disorders supervise utilization
management decisions;
(i) A
comprehensive quality assessment and performance improvement program consistent
with the provisions of Section
394.907, F.S. Such program shall
include an analysis of a representative sample of both current and closed cases
to determine whether:
1. The intake
assessments performed after enrollments are thorough, timely, complete, and
appropriate to the child's presenting condition,
2. The service goals and objectives are based
on the results of the intake assessments and include the concerns of the
enrolled child and his family,
3.
The services delivered are consistent with the service goals and objectives
outlined in the Treatment Plan,
4.
The services delivered are appropriate based on the enrolled child's presenting
condition and are in compliance with the Lead Agency's clinical policies, scope
of services and practice guidelines as indicated,
5. The management information system tracks
how client data is monitored and reported, ensures it is complete and accurate
based on the presenting conditions of the children being served, and is
utilized in performance improvement,
6. The process for grievances and appeals is
accessible, and affords the child and his family due process in circumstances
where behavioral health services were denied, suspended or reduced and that a
child and his family grievances and appeals are documented, implemented, and
resolved within 45 days of the filing of the grievance or appeal; and,
7. All protocols developed or
adopted by the Lead Agency for the provision, monitoring and reporting of
services, are being followed by its network members and subcontracted Providers
of Behavioral Health Services.
(5) Continuity. Lead Agencies shall ensure
continuity and coordination of services throughout their Behavioral Health Care
Network in order to improve access and quality of care for enrolled children
by:
(a) Coordinating available services within
and without the Lead Agency's Behavioral Health Network;
(b) Sharing and exchanging information across
all levels of care and all behavioral health providers, to the extent
authorized by the child and the family and allowed under state statute and
federal regulation;
(c) Developing
written policies and procedures approved by the department to ensure that
enrolled children and their families receive timely access to and follow-up
with appropriate behavioral health providers, including a psychiatrist for
medication management and psychiatric assessment;
(d) Developing written policies and
procedures approved by the department in conjunction with Children's Medical
Services to ensure that enrolled children receive continuity and coordination
of behavioral health services with general medical care;
(e) Developing written policies and
procedures approved by the department to ensure continuity of services for
children being disenrolled by the network as well as children being received or
transferred to and from out-of-network providers upon entry into service and
disenrollment is accomplished without disruption of services to the child; and,
(f) Developing written policies
and procedures approved by the department to ensure prior authorization for all
urgent and routine care provided outside of any contracted or subcontracted
out-of network arrangement. These policies and procedures shall include
provisions for the enrolled child's access to and payment for Behavioral Health
Services provided out-of-network.
(6) Out-of-Network Service Utilization. The
Lead Agency shall make available its approved policies in accessing
out-of-network coverage and ensure all children and their families are aware of
its written policies and procedures governing out-of-network service
utilization. The Lead Agency shall provide enrollees identification card and
outreach materials, the telephone number that an enrolled child and
out-of-network provider may call for information about covered
service.
(7) The Lead Agency shall
ensure that enrolled children and their families are advised that with the
exception of emergency services the Lead Agency shall not be liable for the
cost of out-of-network services the child accesses that are available through
its Behavioral Health Care Network in which the child is enrolled unless
specifically authorized by the Lead Agency.
(8) Emergency Out-of-Network Service
Utilization. A Provider of Behavioral Health Services shall not require prior
authorization for the provision of Emergency Behavioral Health Care to an
enrolled child.
(a) The Lead Agency shall not
be responsible for payment of services delivered after twenty-four hours of the
authorization of admission unless the Lead Agency has specifically authorized
the delivery of such services.
(b)
The Lead Agency shall reimburse out-of-network providers for properly completed
and submitted claims for Emergency Behavioral Health Care provided that such
claims are submitted within 90 days of the date of service. The Lead Agency
shall adjudicate such claim within 60 days of receipt. A claim shall be
considered properly completed and submitted when the following occurs:
1. The claim documents psychiatric admission
for the treatment of Emergency Behavioral Health Care as defined in subsection
65E-11.002(12),
F.A.C., and includes the date of admission, reason for admission, location of
the treatment facility, duration of service noted, and any Behavioral Health
Services authorized by the referring Lead Agency.
2. The claim includes documentation of the
out-of-network provider's notification to the Lead Agency of the presenting
child receipt of services within 24 hours of learning the child's identity or
its attempts to notify the Lead Agency of the child presenting for Emergency
Behavioral Health Care and the circumstances that precluded its attempts to
notify the Lead Agency; and,
3.
Charges mutually agreed to by the Lead Agency and the provider within 60 days
after submittal of the claim.
(9) The Lead Agency shall be liable for
charges for Emergency Behavioral Health Care pursuant to the provisions of
Section 394.451, F.S., the "The Florida
Mental Health Act" also known as "The Baker Act." with regard to admissions and
assessments with reimbursement to the treating facility not to exceed the
Medicaid approved rate for Baker Act admissions and assessments.
(10) Lead Agencies shall be responsible for
the management of the enrollment pool which shall include the application of
screenings and assessments to potential entrants to the pool and the conducting
of reverification screenings among existing enrolled children. The costs of
such services shall be borne by the Lead Agency.
(11) Service Delivery Location.
All Behavioral Health Services shall be accessible in a setting which is
located no further than a thirty (30) minute typical drive time from the
residence of the enrolled child accessing the care.
(12) Exceptions to the drive-time provision
shall be made by the Behavioral Health Network Coordinator to address the lack
of specialty providers or other service constraints existing in rural
areas.
(13) Service Times.
Providers of Behavioral Health Services shall at a minimum, be available during
normal business hours to provide direct services to children and to carry out
activities related to clinical administration and shall comply with the
following service standards:
(a) Emergency
Behavioral Health Care shall be unrestricted and directly accessible to the
enrolled child, twenty-four (24) hours a day and seven (7) days a
week.
(b) Urgent Care as defined in
subsection 65E-11.002(27),
F.A.C., shall be evaluated and delivered within twenty-four (24)
hours.
(c) Routine Care must be
provided within ten (10) days of the request from a child or the
family.
(14) Records and
Documentation. Providers of Behavioral Health Services shall maintain written
service documentation to support each service rendered on behalf of the
enrolled child. Service documentation must contain all of the following:
(a) Recipient's name;
(b) Date the service was rendered;
(c) Start and end times for the
services;
(d) Identification of the
setting in which service was rendered;
(e) Reference to the treatment plan goal and
objectives for which service is being provided;
(f) Description of the specific service
rendered, including the specific intervention;
(g) Updates regarding the recipient's
progress toward meeting goals and objectives identified in the treatment plan;
and,
(h) Original signature,
credential and functional title of the person providing the
service.
Rulemaking Authority
409.8135(6) FS.
Law Implemented 409.8135
FS.
New 1-17-01, Amended
8-31-03.
