New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 588 - Medical Assistance Payment For Outpatient Programs
Section 588.7 - Standards pertaining to reimbursement for continuing day treatment programs

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 588.7

Current through Register Vol. 46, No. 39, September 25, 2024

(a) For services provided on or after January 1, 2009, and prior to April 1, 2009, continuing day treatment visits other than collateral, group collateral and crisis visits shall be reimbursed on the basis of duration of hours provided as follows:

(1) Reimbursement shall be provided for visits of at least one hour duration.

(2) Reimbursement shall be provided for no more than five hours per recipient per day.

(b) For services provided on or after January 1, 2009, and prior to April 1, 2009, collateral visits shall be reimbursed for clinical support services of at least 30 minutes duration but not more than two hours of face-to-face interaction between one or more collaterals and one therapist with or without a recipient.

(c) For services provided on or after January 1, 2009, and prior to April 1, 2009, group collateral visits shall be reimbursed for clinical support services, in accordance with section 587.4(c) of this Title, of at least 60 minutes in duration but not more than two hours and shall represent service to more than one patient and/or his or her collaterals. Such visits need not include patients but shall not include more than 12 collaterals and/or recipients in a face-to-face interaction with a therapist.

(d) For services provided on or after April 1, 2009, continuing day treatment visits, other than collateral, group collateral, pre-admission and crisis visits, shall be reimbursed on the basis of duration of hours provided as follows:

(1) A half-day visit shall be for a minimum duration of two hours. To be eligible for reimbursement for a half-day visit, one or more medically necessary service(s) shall be provided and documented.

(2) A full-day visit shall be for a minimum duration of four hours. To be eligible for reimbursement for a full-day visit, three or more medically necessary services shall be provided and documented.

(e) For services provided on or after April 1, 2009, collateral visits shall be clinical support services of at least 30 minutes duration of face-to-face interaction documented by the provider between one or more collaterals and/or family members of the same enrolled recipient and one therapist with or without a recipient. Collateral visits shall be reimbursed as a half-day visit.

(f) For services provided on or after April 1, 2009, group collateral visits shall be clinical support services of at least 60 minutes duration of face-to-face interaction documented by the provider between collaterals and/or family members of multiple recipients of the continuing day treatment provider and one therapist with or without the recipients. Group collateral visits shall be reimbursed as a half-day visit.

(g) For services provided on or after April 1, 2009, crisis visits shall be reimbursed as a half-day visit for crisis intervention services of face-to-face interaction documented by the provider between a recipient and a therapist, regardless of the actual duration of the visit.

(h) For services provided on or after April 1, 2009, preadmission visits shall be services of at least 60 minutes duration of face-to-face interaction documented by the provider between a recipient and a therapist. Preadmission visits shall be reimbursed as a half-day visit.

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

(1) a review of the appropriateness of admission to a continuing day treatment program by the 12th visit or within 30 days after admission;

(2) a review of the need for continued treatment in a continuing day treatment program within seven months after admission and every six months thereafter.

(j) The determination of need for admission to or continued treatment in a continuing day treatment program shall be reviewable by the Office of Mental Health or its designated agent, and shall take the following criteria into account:

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

(2) whether the recipient requires services at that level of care, or would be more appropriately discharged or referred to another program; and

(3) if applicable, the availability of a viable alternative program.

(k) The treatment plan required pursuant to section 587.16 of this Title shall be completed prior to the 12th visit after admission or within 30 days of admission, whichever occurs first. Review of the treatment plan shall be every three months.

(l) The need for continuing day treatment benefits beyond 156 visits per year shall be determined in accordance with subdivision (m) of this section, no later than the 156th visit during such year. Such determination shall include an estimate of the number of visits beyond 156 required for the recipient within the remaining year. The need for continued continuing day treatment benefit beyond this estimated number of visits shall be determined at or prior to the provision of the estimated number of visits during the year. The need for any additional revised estimates shall be determined accordingly.

(m) Determinations required in accordance with subdivision (l) of this section shall be:

(1) completed by the treating clinician;

(2) documented in the case record; and

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

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