Psychiatric day treatment is a service in a continuum of
care designed to prevent hospitalization or to facilitate the movement of the
acute psychiatric client to a status in which the client is capable of
functioning within the community with less frequent contact with the
psychiatric health care provider.
Day treatment services must meet all requirements in 471 NAC
20-001.
003.01
Covered Day Treatment
Services
Psychiatric day treatment programs shall provide the
following mandatory services and at least two of the following optional
services. Payment for both mandatory services and optional services is included
in the rate for day treatment. Providers shall not make any additional charges
to the Department or to the client.
20-003.01A
Mandatory
Services: The following services must be included in a program for
psychiatric day treatment to be approved for participation in the Nebraska
Medical Assistance Program. See 471 NAC
20-001 for definitions.
1.
Medically Necessary
Psychotherapy Services: These services must demonstrate active
treatment of a patient with a psychiatric condition. These services are subject
to program limitations and must be provided by professionals operating within
the appropriate scope of practice.
a.
Individual Psychotherapy;
b. Group
Psychotherapy;
c. Family
Psychotherapy;
d. Family Assessment
if appropriate;
2.
Medically Necessary Nursing Services: Services
directed by a Registered Nurse who evaluates the particular medical nursing
needs of each client and provides for the care and treatment that is indicated
by the Department approved treatment planning document approved by the
supervising practitioner.
3.
Medically Necessary Psychological Diagnostic Services:
Testing and evaluation services must reasonably be expected to contribute to
the diagnosis and plan of care established for the individual client. Testing
and evaluation services may be performed by a Licensed Psychologist. If testing
and evaluation services are provided by a specially licensed psychologist or
approved Master's level person, the services must be ordered by a supervising
practitioner. Medical necessity must be documented by the supervising
practitioner. Reimbursement for psychological Diagnostic Services is included
in the per diem and will not be reimbursed for separately.
4.
Medically Necessary
Pharmaceutical Services: If medications are dispensed by the
program, pharmacy services must be provided under the supervision of a
registered pharmacy consultant; or the program may contract for these services
through an outside licensed/certified facility. All medications must be stored
in a special locked storage space and administered only by a physician,
registered nurse, or licensed practical nurse.
5.
Medically Necessary Dietary
Services: If meals are provided by a day treatment program,
services must be supervised by a registered dietitian, based on the client's
individualized medical diet needs. The program may contract for these services
through an outside licensed certified facility.
6. Transition and discharge planning must
meet the requirements of 471 NAC 20001.18.
20-003.01B
Optional
Services: The program must provide two of the following optional
services. The client must have a need for the services, a supervising
practitioner must order the services, and the services must be a part of the
client's treatment plan. The therapies must be restorative in nature, not
prescribed for conditions that have plateaued or cannot be significantly
improved by the therapy, or which would be considered maintenance therapy. In
appropriate circumstances, occupational therapy may be covered if prescribed as
an activities therapy in a psychiatric program:
1. Services provided or supervised by a
licensed or certified therapist may be provided under the supervision of a
qualified consultant or the program may contract for these services from a
licensed/certified professional as listed below:
a. Recreational Therapy;
b. Speech Therapy;
c. Occupational Therapy;
d. Vocational Skills Therapy;
e. Self-Care Services: Services supervised by
a registered nurse or occupational therapist who is oriented toward activities
of daily living and personal hygiene. This includes toileting, bathing,
grooming, etc.
2. Social
Work provided by a bachelor's level social worker: Social services to assist
with personal, family, and adjustment problems which may interfere with
effective use of treatment, i.e., case management type services.
3. Social Skills Building;
4. Life Survival Skills.
20-003.01C
Special Treatment
Procedures in Day Treatment: If a client needs behavior management
and containment beyond unlocked time outs or redirection, special treatment
procedures may be utilized. Special treatment procedures in day treatment are
limited to physical restraint, and locked time out (LTO). Mechanical restraints
and pressure point tactics are not allowed.
Facilities must meet the following standards regarding
special treatment procedures:
1.
De-escalation techniques must be taught to staff and used appropriately before
the initiation of special treatment procedures;
2. Special treatment procedures may be used
only when a client's behavior presents a danger to self or others, or to
prevent serious disruption to the therapeutic environment; and
3. The client's treatment plan must address
the use of special treatment procedures and have a clear plan to decrease the
behavior requiring LTO or physical restraints.
These standards must be reflected in all aspects of the
treatment program. Attempts to de-escalate, the special treatment procedure and
subsequent processing must be documented in the clinical record and reviewed by
the supervising practitioner.
003.02
Standards for
Participation
20-003.02A
Provider Standards: Providers of day treatment
services shall meet the following standards:
1.
Non-Hospital Based Day
Treatment: A center providing day treatment must be -
a. Appropriately licensed by the Nebraska
Department of Health and Human Services, Division of Public Health;
and
b. Accredited by JCAHO, CARF,
COA, or AOA.
2.
Hospital Based Day Treatment: A hospital providing
on-site day treatment must -
a. Be licensed
or formally approved as a hospital by the Nebraska Department of Health and
Human Services, Division of Public Health;
b. Be accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or AOA;
c. Meet the requirements for participation in
Medicare; and
d. Have in effect a
utilization review plan applicable to all Medicaid clients.
When hospitals provide services in freestanding facilities,
the freestanding facility must be appropriately licensed by the Nebraska
Department of Health and Human Services, Division of Public Health.
20-003.02B
Service Standards:
1. The program must provide a minimum of
three hours of services five days a week, which is considered a half day for
billing purposes. A minimum of six hours a day is considered a full day of
service. Services may not be prorated for under three (or six) hours of
services;
2. A designated
supervising practitioner must be responsible for the psychiatric care in a day
treatment program. The supervising practitioner must be present on a
regularly-scheduled basis and must assume clinical responsibility for all
patients. If the supervising practitioner is present on a part-time basis, one
of the following shall assume delegated professional responsibility for the
program and must be present at all times when the program is providing
services:
a. A licensed physician;
b. A licensed psychologist;
c. Licensed Independent Mental Health
Practitioner; or
d. An allied
health therapist;
3. Any
supervising practitioner may refer a client to a day treatment program, but all
treatment must be prescribed and directed by the program supervising
practitioner;
4. All treatment must
be conducted under the supervision of the supervising practitioner in charge of
the program;
5.
Psychotherapy Staff: See 471 NAC
20-001 for definitions.
a. Physician;
b. Licensed Psychologist;
c. Licensed Independent Mental Health
Practitioner; and
d. Allied health
therapists. All psychotherapy services provided by allied health therapists
must be prescribed by the supervising practitioner and provided under his/her
supervision. The supervising practitioner's personal involvement in all aspects
of the client's psychiatric care must be documented in the client's medical
record (i.e., physician's orders, progress notes, nurses notes).
6. Admission Criteria: The
following criteria must be met for a client's admission to a psychiatric day
treatment program:
a. The client must have
sufficient medical need for active psychiatric treatment at the time of
admission to justify the expenditure of the client's and program's time,
energy, and resources; and
b. Of
all reasonable options for active psychiatric treatment available to the
client, treatment in this program must be the best choice for expecting a
reasonable improvement in the client's psychiatric condition.
7. Pre-Admission Evaluation: The
need for this level of care must be recommended on the pre-treatment assessment
or addendum. Before the client is admitted to the program, the supervising
practitioner shall complete an Initial Diagnostic Interview to validate the
appropriateness of care. When a client is transferred from inpatient hospital
care to day treatment, the inpatient evaluation and discharge summary
documenting the rationale of transfer as part of the treatment plan serves the
same purpose as the Initial Diagnostic Interview. The evaluation must be filed
in the client's medical record. The preadmission evaluation must include -
a. A clinical assessment of the health status
and related psychological, medical, social, and educational needs of the
client; and
b. A determination of
the range and kind of services required.
The supervising practitioner shall personally complete an
Initial Diagnostic Interview which must be used to develop the plan of care if
all admission criteria have been met;
8. Treatment Plan: The program supervising
practitioner shall determine the psychiatric diagnosis and prescribe the
treatment, including the modalities and the professional staff to be used.
He/she must be responsible and accountable for all evaluations and treatment
provided to the client.
The goals and objectives documented on the treatment plan
must reflect the recommendations included in the Pre-treatment Assessment and
the integration of input from the supervising practitioner and the therapist.
The treatment interventions provided must reflect these recommendations, goals,
and objectives. Evaluation of the treatment plan by the therapist and the
supervising practitioner should reflect the client's response to the treatment
interventions based on the recommendations, goals and objectives.
The treatment plan shall be completed upon the client's
admission to the program;
9. At least every 30 days thereafter, a
treatment plan review must be conducted by the multi-disciplinary team,
including the supervising practitioner. The treatment plan review must be
documented on the Department approved treatment planning document (if
required), and in the treatment plan. The facility's treatment plan review
format, if approved by the Department, may function as the Department approved
treatment planning document.
The Department approved treatment planning document must be
signed by the program supervising practitioner for day treatment
services;
10. The
supervising practitioner must personally evaluate the client every 30 days, or
more often, as medically necessary. This evaluation must occur in a one-to-one,
face-to-face session separate from the treatment plan review;
11. Every 30 days a utilization review must
be conducted per 471 NAC 20-003.07. This review must be documented on the
Department approved treatment planning document (if required) and the
facility's treatment plan review form. Utilization review is not required for
the calendar month in which the client was admitted;
12. The program must have a description of
each of the services and treatment modalities available. This includes
psychotherapy services, nursing services, psychological diagnostic services,
pharmaceutical services, dietary services, and other psychiatric day treatment
services.
a. The program must have a
description of how the family-centered requirement in 471 NAC
20-001 will be met, including a
complete description of any family assessment and family psychotherapy
services.
Providers must encourage family members to be involved in the
assessment of the client, the development of the treatment plan, and all
aspects of the client's treatment unless prohibited by the client, through
legal action, or because of federal confidentiality laws.
Providers must be available to schedule meetings and sessions
in a flexible manner to accommodate and work with a family's schedule. This
includes the ability to schedule sessions at a variety of times including
weekends or evenings.
The provider must document their attempts to involve the
family in treatment plan development and treatment plan reviews. A variety of
communication means should be considered. These may include, but should not be
limited to, including the family via conference telephone calls, using
registered letters to notify the family of meetings, and scheduling meetings in
the evening and on weekends;
b. The program must have a description of how
the community-based requirement in 471 NAC
20-001 will be met;
c. The program shall state the
qualifications, education, and experience of each staff member and the therapy
services each provides.;
d. The
program must have a daily schedule covering the total number of hours the
program operates per day. The schedule must be submitted to the Department for
approval. The program must be fully staffed and supervised during the time the
program is available for services, and must provide at least three hours of
approved treatment for each day services are provided. This schedule must be
updated annually, or more frequently if appropriate;
13. Outpatient Observation: When appropriate
for brief crisis stabilization, outpatient observation up to 23 hours 59
minutes in an emergency room or acute hospital may be used as follows:
An outpatient is defined as a person who has not been
admitted as an inpatient but is registered on the hospital records as an
outpatient and receives services (rather than supplies alone). If a patient
receives 24 or more hours of continuous outpatient care, that patient is
defined as an inpatient regardless of the hour of admission, whether s/he used
a bed and whether s/he remained in the hospital past midnight or the
census-taking hour, and all inpatient medical review prior-authorization
requirements apply;
14. The
program must have a written plan for immediate admission or readmission for
appropriate inpatient psychiatric services, if necessary. The written plan must
include a cooperative agreement with a psychiatric hospital or distinct part of
a hospital, as outlined in 471 NAC
20-007. A copy of this agreement must
accompany the provider application and agreement.
003.03
Provider
Agreement
A provider of psychiatric day treatment services shall
complete a provider agreement and submit the form to the Department for
approval. The provider shall attach to the provider application and agreement a
written overview of the program including philosophy, objectives, policies and
procedures, confirmation that the requirements in 471 NAC
20-001 and 471 NAC
20-002 are met and any other
information requested by Medicaid staff. Staff must meet the standards outlined
in 471 NAC 20-001.13; and:
1.
Community mental health programs and licensed mental health clinics shall
complete Form MC-19, "Medical Assistance Provider Agreement," and submit the
completed form to the Department for approval. A Department approved cost
reporting document (FA-20) must also be submitted. The provider application and
agreement must be renewed annually to coincide with the submittal of the cost
report. Satellites of community mental health programs shall bill the
Department through their main community mental health program, unless the
satellite has a separate provider number under Medicare. A satellite of a
community mental health program that has a separate provider number under
Medicare shall complete a separate provider agreement. All claims submitted to
the Department by these satellites must be filed under the satellite's Medicaid
provider number. The facility must have in effect a utilization review plan
applicable to all Medicaid clients.
2. Hospitals shall complete Form MC-20,
"Medical Assistance Hospital Provider Agreement," and submit the completed form
to the Department for approval. A Department approved cost reporting document
(FA-20) must also be submitted.
20-003.03A
Annual
Update: The program shall update the provider agreement, program
overview, and cost report annually and whenever requested by the Division of
Medicaid and Long-Term Care.
003.04
Coverage Criteria for Day
Treatment Psychiatric Services
The Nebraska Medical Assistance Program covers psychiatric
day treatment services for clients 21 and over when the services meet the
requirements in 471 NAC
20-001.
The client must be observed and interviewed by the program
supervising practitioner at least every 30 days or more frequently if medically
necessary and the interaction must be documented in the client's medical
record.
20-003.04A
Services Not Covered Under Medicaid: Payment is not
available for psychiatric day treatment services for clients -
1. Receiving services in an out-of-state
facility, except as outlined in 471 NAC 1002, Services Provided Outside
Nebraska;
2. Living in long term
care facilities or Institutes for Mental Disease;
3. Whose needs are social or educational and
may be met through a less structured program;
4. Whose primary diagnosis and functional
impairment is psychiatric in nature but is not stable enough to allow them to
participate in and benefit from the program; or
5. Whose behavior may be very disruptive
and/or harmful to other program participants or staff members.
003.05
Documentation in the Client's Clinical Record
All documents submitted to Medicaid must contain sufficient
information for identification (i.e., client's name, dates of service,
provider's name) and must be legible. Each client's clinical record must
contain the following documentation:
1. The supervising practitioner's
orders;
2. The Initial Diagnostic
Interview and referral documented by the supervising practitioner;
3. The treatment plan;
4. The team progress notes, recorded
chronologically. The frequency is determined by the client's condition, but the
team's progress notes must be recorded at least weekly. The progress notes must
contain a concise assessment of the client's progress and recommendations for
revising the treatment plan, as indicated by the client's condition, and
discharge planning;
5.
Documentation indicating compliance with all requirements in 471 NAC
20-001;
6. The program's utilization review
committee's abstract or summary; and
7. The discharge summary.
003.06
Transition and
Discharge Planning
Each provider must meet the 471 NAC
20-001 requirements for transition
and discharge planning.
003.07
Utilization Review
(UR)
Each program is responsible for establishing a utilization
review plan and procedure which meets the following guidelines. A site visit by
Medicaid staff for purposes of utilization review may be required for further
clarification.
20-003.07A
Components of UR: Utilization review must provide -
1. Timely review (at least every 30 days) of
the medical necessity of admissions and continued treatment;
2. Utilization of professional services
provided;
3. High quality patient
care; and
4. Effective and
efficient utilization of available health facilities and services.
20-003.07B
UR
Overview: An overview of the program's utilization review process
must be submitted with the provider application and agreement before the
program is enrolled as a Medicaid provider. The overview must include -
1. The organization and composition of the
utilization review committee which is responsible for the utilization review
function;
2. The frequency of
meetings (not less than once a month);
3. The type of records to be kept;
and
4. The arrangement for
committee reports and their dissemination, including how the supervising
practitioner is informed of the findings.
20-003.07C
UR
Committee: The utilization review committee must consist of a
supervising practitioner and at least two mental health practitioners (as
defined in 471 NAC
20-001). A licensed psychologist may
replace one of the allied health staff members. The committee's reviews may not
be conducted by any person whose primary interest in or responsibility to the
program is financial or who is professionally involved in the care of the
client whose case is being reviewed. At the Department's discretion, an
alternative plan for facilities that do not have these resources readily
available may be approved.
20-003.07D
Basis of
Review: The review must be based on -
1. The identification of the individual
client by appropriate means to ensure confidentiality;
2. The identification of the supervising
practitioner;
3. The date of
admission;
4. The diagnosis and
symptoms;
5. The supervising
practitioner plan of treatment; and
6. Other supporting materials (progress
notes, test findings, consultations) the group may deem appropriate.
20-003.07E
Contents of
Report: The written report must contain -
1. An evaluation of treatment, progress, and
prognosis based on -
a. Appropriateness of
the current level of care and treatment;
b. Alternate levels of care and treatment
available; and
c. The effective and
efficient utilization of services provided;
2. Verification that -
a. Treatment provided is documented in the
client's record;
b. All entries in
the client's record are signed by the person responsible for entry. The
supervising practitioner shall sign all orders; and
c. All entries in the client's record are
dated;
3.
Recommendations for -
a. Continued
treatment;
b. Alternate
treatment/level of care; and
c.
Disapproval of continued treatment.
4. The date of the review;
5. The names of the program utilization
review committee members; and
6.
The date of the next review if continued treatment is recommended.
A copy of the admission review and the extended stay review
must be attached to all claims for psychiatric services submitted to the
Department for payment.
003.08
Payment for Psychiatric
Day Treatment Services
Payment for psychiatric day treatment services will be based
upon rate setting by the Department.
Payment rates for psychiatric day treatment services for
individuals age 21 and older will be on a unit basis. Rates are set annually,
for the period July 1 through June 30. Rates are set prospectively for this
period, and are not adjusted during the rate period.
Providers are required to report their costs on an annual
basis. Providers may choose any fiscal year end that they desire. Providers
desiring to enter the program who have not previously reported their costs, or
that are newly operated, are to submit a budgeted cost report, estimating their
anticipated annual costs.
Providers shall submit cost and statistical data on Form
FA-20. The provider shall submit one original Form FA-20 to the Department
within 90 days of the close of fiscal year, or change in ownership or
management. One 15-day extension may be granted under extenuating circumstances
if requested, in writing, prior to the date. Providers shall compile data based
on generally accepted accounting principles and the accrual method of
accounting based on the provider's fiscal year. Financial and statistical
records for the period covered by the cost report must be accurate and
sufficiently detailed to substantiate the data reported. All records must be
readily available upon request by the Department for verification. If the
provider fails to file a cost report as due, the Department will suspend
payment. At the time the suspension is imposed, the Department will send a
letter informing the provider that no further payment will be made until a
proper cost report is filed.
In setting payment rates, the Department will consider those
costs which are reasonable and necessary for the active treatment of the
clients being served. Such costs will include those necessary for licensure and
accreditation, meeting all staffing standards for participation, meeting all
service standards for participation, meeting all requirements for active
treatment, maintaining medical records, conducting utilization review, meeting
inspection of care requirements and discharge planning.
The Department does not guarantee that all costs will be
reimbursed. The Form FA-20 cost reporting document is used by the Department
only as a guide in the rate setting process. Actual costs incurred by the
providers may not be entirely reimbursed.
20-003.08A
Payment Rates for
Psychiatric Day Treatment Services Provided by State-Operated
Facilities: Psychiatric day treatment centers operated by the
State of Nebraska will be reimbursed for all reasonable and necessary costs of
operation, excluding educational services. State-operated centers will receive
an interim payment rate, with an adjustment to actual costs following the cost
reporting period.
20-003.08B
Unallowable Costs: The following costs are not
allowable:
1. Provisions for income
tax;
2. Fees paid board of
directors;
3. Non-working officers'
salaries;
4. Promotion expense,
except for promotion and advertising as allowed in HIM-15. Yellow Page display
advertising is not allowable; one Yellow Page informational listing is
allowable;
5. Travel and
entertainment, other than for professional meetings and direct operations of
the day treatment program. This may include costs of motor homes, boats, and
other recreational vehicles, including operation and maintenance expenses; real
property used as vacation facilities; etc.;
6. Donations;
7. Expenses of non-related facilities and
operations included in expense;
8.
Insurance and/or annuity premiums on the life of officer or owner;
9. Bad debts, charity, and courtesy
allowances;
10. Cost and portions
of costs which are determined by the Department not to be reasonably related to
the efficient production of service because of either the nature or amount of
the particular expenditure;
11.
Education costs;
12. Services
provided by the clients' physicians or dentists, drugs, laboratory services,
radiology services, or services provided by similar independent licensed
providers, except services provided by state operated facilities. These
exclusions are paid separately;
13.
Return on equity;
14. Costs for
services which occurred in a prior or subsequent fiscal year are
unallowable;
15. Expenses for
equipment, facilities, and programs (e.g., recreation, trips) provided to
clients which are determined by the Department not to be reasonably related to
the efficient production of service because of either the nature or amount of
the particular service;
16. Costs
of amusements, social activities, and related expenses for employees and
governing body members are unallowable, except when part of an authorized
client treatment program;
17. Costs
of alcoholic beverages are unallowable;
18. Costs resulting from violations of, or
failure to comply with federal, state, and local laws and regulations are
unallowable;
19. Costs relating to
lobbying or attempts to influence/promote legislative action by local, state,
or federal government are unallowable; and
20. Costs of lawsuits or other legal or court
proceedings against the Department, or its employees, or State of Nebraska are
unallowable.
20-003.08C
Suspension or Termination of License: The Department
does not make payment for care provided after 30 days following the date of
expiration or termination of the provider's license or certificate to operate
under Title XIX. The Department does not make payment for care provided to
individuals who were admitted after the date of expiration or termination of
the provider's license or certificate to operate under Title XIX.
20-003.08D
Appeal
Process: Final administrative decision or inaction in the rate
setting process is subject to administrative appeal. The provider may request
an appeal, in writing, from the Director for a hearing within 90 days of the
decision or inaction. Regulations for appeals and fair hearings are contained
in 465 NAC 2-001.02 and
2-006 ff.
20-003.08E
Administrative
Finality: An administrative decision or inaction in the allowable
cost determination process, which is otherwise final, may be reopened by the
Department within three years of the date of notice of the decision or
inaction.
"Reopening" is an action taken by the Director to re-examine
or question the correctness of a determination or decision which is otherwise
final. The Director is the sole authority for deciding whether to reopen an
administrative decision or inaction. The action may be taken -
1. On the initiative of the Department within
the three-year period;
2. In
response to a written request of a provider or other entity within the
three-year period. Whether the Director will reopen a determination, which is
otherwise final, depends on whether new and material evidence has been
submitted, a clear and obvious error has been made, or the determination is
found to be inconsistent with any law, regulations and rulings, or general
instructions; or
3. Any time fraud
or abuse is suspected.
A provider has no right to appeal a finding by the Director
that a reopening or correction of a determination or decision is not
warranted.
003.09
Record
Retention
The provider shall retain financial records, supporting
documents, statistical records, and all other pertinent records related to the
cost report for a minimum of five years after the end of the report period. The
Department shall retain all cost reports for at leave five years after receipt
from the provider.
003.10
Billing Requirements
For day treatment services, the following requirements must
be met:
1. Providers of non-hospital
based day treatment services shall submit claims for day treatment services on
an appropriately completed Form CMS-1500 (see 471-000-64) or the standard
electronic Health Care Claim: Professional transaction (ASC X12N 837).
Payment for approved day treatment services is made to the
facility.
2. Providers of
hospital based day treatment services shall submit claims for services on an
appropriately completed Form CMS-1450 or the standard electronic Health Care
Claim: Institutional transaction (ASC X12N 837).
Payment for approved hospital based day treatment services is
made to the hospital.
20-003.10A
Documentation for Claims: The following documentation,
kept in the client's file, is required for all claims for day treatment
services:
1. Initial Diagnostic
Interview;
2. Supervising
practitioner orders;
3. Nurses'
notes; and
4. Progress notes for
all disciplines.
All claims are subject to utilization review by the
Department prior to payment. Reimbursement may be denied if claims and/or
documentation are illegible (see 471 NAC 20-001.19).
20-003.10B
Exception: Additional documentation from the client's
medical record may be requested by the Department prior to considering
authorization of payment. Progress notes for other Medicaid clients may be
requested when the treatment report does not adequately explain family
psychotherapy or medical necessity cannot be determined.
003.11
Procedure Codes
and Descriptions for Psychiatric Day Treatment
HCPCS/CPT procedure codes used by Medicaid are listed in the
Nebraska Medicaid Practitioner Fee Schedule (see 471-000-532).
003.12
Costs Not Included in the
Day Treatment Fee
The mandatory and optional services are considered to be
part of the fee for day treatment services. The following charges can be
reimbursed separately from the day treatment fee when the services are
necessary, part of the client's overall treatment plan, and in compliance with
NMAP policy:
1. Direct client services
performed by the supervising practitioner;
2. Prescription medications (including
injectable medications);
3. Direct
client services performed by a physician other than the supervising
practitioner; and
4. Treatment
services for a physical injury or illness provided by other professionals.
If the client is enrolled with another managed care vendor
for medical-surgical services, it may be necessary to pursue prior
authorization or referral with that entity.
