Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 21 - OUTPATIENT BEHAVIORAL HEALTH AGENCY SERVICES
Section 317:30-5-241.1 - Screening, assessment and service plan
Universal Citation: OK Admin Code 317:30-5-241.1
Current through Vol. 41, No. 20, July 1, 2024
All providers must comply with the requirements as set forth in this Section.
(1) Screening.
(A)
Definition. Screening is for the purpose of determining whether
the member meets basic medical necessity and need for further behavioral health
(BH) assessment and possible treatment services.
(B)
Qualified professional.
Screenings can be performed by any credentialed staff members as listed under
OAC
317:30-5-240.3.
(C)
Target population and
limitations. Screening is compensable on behalf of a member who is
seeking services for the first time from the contracted agency. This service is
not compensable if the member has previously received or is currently receiving
services from the agency, unless there has been a gap in service of more than
six (6) months. To qualify for reimbursement, the screening tools used must be
evidence-based or otherwise approved by Oklahoma Health Care Authority (OHCA)
and Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS)
and appropriate for the age and/or developmental stage of the
member.
(2) Assessment.
(A)
Definition. Gathering and assessment of historical and current
bio-psycho-social information which includes face-to-face contact with the
person and/or the person's family or other person(s) resulting in a written
summary report, diagnosis and recommendations. All agencies must assess the
medical necessity of each individual to determine the appropriate level of
care.
(B)
Qualified
practitioners. This service is performed by a licensed behavioral health
professional (LBHP) or licensure candidate.
(C)
Target population and
limitations. The BH assessment is compensable on behalf of a member who
is seeking services for the first time from the contracted agency. This service
is not compensable if the member has previously received or is currently
receiving services from the agency, unless there has been a gap in service of
more than six (6) months and it has been more than one (1) year since the
previous assessment.
(D)
Documentation requirements. The assessment must include all
elements and tools required by the OHCA. In the case of children under the age
of eighteen (18), it is performed with the direct, active face-to-face
participation of the parent or guardian. The child's level of participation is
based on age, developmental and clinical appropriateness. The assessment must
include at least one DSM diagnosis from the most recent DSM edition or
diagnostic impression. The information in the assessment must contain but is
not limited to the following:
(i) Behavioral,
including substance use, abuse, and dependence;
(ii) Emotional, including issues related to
past or current trauma;
(iii)
Physical;
(iv) Social and
recreational;
(v)
Vocational;
(vi) Date of the
assessment sessions as well as start and stop times; and
(vii) Signature of parent or guardian
participating in face-to-face assessment. Signatures are required for members
over the age of fourteen (14). Signature and credentials of the practitioner
who performed the face-to-face behavioral assessment. The signatures may be
included in a signature page applicable to both the assessment and treatment
plan if the signature page clearly indicates that the signatories consent and
approve of both.
(3) Behavioral Health Services Plan Development.
(A)
Definition. The Behavioral Health Service Plan is developed based
on information obtained in the assessment and includes the evaluation of all
pertinent information by the practitioners and the member, including a
discharge plan. It is a process whereby an individualized plan is developed
that addresses the member's strengths, functional assets, weaknesses or
liabilities, treatment goals, objectives and methodologies that are specific
and time limited, and defines the services to be performed by the practitioners
and others who comprise the treatment team. Behavioral Health Service Plan
Development is performed with the direct active participation of the member and
a member support person or advocate if requested by the member. In the case of
children under the age of eighteen (18), it is performed with the participation
of the parent or guardian and the child as age and developmentally appropriate,
and must address school and educational concerns and assisting the family in
caring for the child in the least restrictive level of care. For adults, it is
focused on recovery and achieving maximum community interaction and involvement
including goals for employment, independent living, volunteer work, or
training. A Service Plan Development, Low Complexity is required every six (6)
months and must include an update to the bio-psychosocial assessment and
re-evaluation of diagnosis.
(B)
Qualified practitioners. This service is performed by an LBHP or
licensure candidate.
(C)
Time
requirements. Service Plan updates must be conducted face-to-face and
are required every six (6) months during active treatment. However, updates can
be conducted whenever it is clinically needed as determined by the qualified
practitioner and member, but are only compensable twice in one (1)
year.
(D)
Documentation
requirements. Comprehensive and integrated service plan content must
address the following:
(i) member strengths,
needs, abilities, and preferences (SNAP);
(ii) identified presenting challenges,
problems, needs and diagnosis;
(iii) specific goals for the member;
(iv) objectives that are specific,
attainable, realistic, and time-limited;
(v) each type of service and estimated
frequency to be received;
(vi) the
practitioner(s) name and credentials that will be providing and responsible for
each service;
(vii) any needed
referrals for service;
(viii)
specific discharge criteria;
(ix)
description of the member's involvement in, and responses to, the service plan,
and his/her signature and date;
(x)
service plans are not valid until all signatures are present signatures are
required from the member, if fourteen (14) or over, the parent/guardian if
younger than eighteen (18) or otherwise applicable, and the primary LBHP or
licensure candidate. The signatures may be included in a signature page
applicable to both the assessment and treatment plan if the signature page
clearly indicates that the signatories consent and approve of both;
and
(xi) all changes in a service
plan must be documented in either a scheduled six (6) month service plan update
(low complexity) or within the existing service plan through an amendment until
time for the update (low complexity). Any changes to the existing service plan
must, prior to implementation, be signed and dated by the member if fourteen
(14) or over, the parent/guardian if younger than eighteen (18) or otherwise
applicable, and the lead LBHP or licensure candidate.
(xii) Amendment of an existing service plan
to revise or add goals, objectives, service provider, service type, and service
frequency, may be completed prior to the scheduled six (6) month review/update.
A plan amendment must be documented through an addendum to the service plan,
dated and signed prior to the implementation, by the member if fourteen (14) or
over, the parent/guardian if younger than eighteen (18) or otherwise
applicable, and the lead LBHP or licensure candidate. A temporary change of
service provider may be documented in the progress note for the service
provided, rather than an amendment.
(xiii) Behavioral health service plan
development, low complexity, must address the following:
(I) update to the bio-psychosocial
assessment, re-evaluation of diagnosis service plan goals and/ or
objectives;
(II) progress, or lack
of, on previous service plan goals and/or objectives;
(III) a statement documenting a review of the
current service plan and an explanation if no changes are to be made to the
service plan;
(IV) change in goals
and/or objectives (including target dates) based upon member's progress or
identification of new need, challenges and problems;
(V) change in frequency and/or type of
services provided;
(VI) change in
practitioner(s) who will be responsible for providing services on the
plan;
(VII) change in discharge
criteria;
(VIII) description of the
member's involvement in, and responses to, the service plan, and his/her
signature and date; and
(IX)
service plan updates (low complexity) are not valid until all signatures are
present. The required signatures are: from the member if fourteen (14) or over,
the parent/guardian if younger than eighteen (18) or otherwise applicable, and
the primary LBHP or licensure candidate.
(E)
Service limitations:
(i) Behavioral Health Service Plan
Development, Moderate Complexity (i.e., pre-admission procedure code group) is
limited to one (1) per member, per provider, unless more than one (1) year has
passed between services, in which case, one can be requested and performed, if
authorized by OHCA or its designated agent.
(ii) Behavioral Health Service Plan
Development, Low Complexity: Service Plan updates are required every six (6)
months during active treatment. Updates, however, can be conducted whenever
clinically needed as determined by the provider and member, but are only
reimbursable twice in one (1) year. The date of service is when the service
plan is complete and the date the last required signature is obtained. Services
should always be age, developmentally, and clinically appropriate.
(4) Assessment/Evaluation testing.
(A)
Definition.
Assessment/Evaluation testing is provided by a clinician utilizing tests
selected from currently accepted assessment test batteries. Test results must
be reflected in the Service Plan. The medical record must clearly document the
need for the testing and what the testing is expected to achieve.
(B)
Qualified practitioners.
Assessment/Evaluation testing will be provided by a psychologist, certified
psychometrist, psychological technician of a psychologist, an LBHP or licensure
candidate. For assessments conducted in a school setting, the Oklahoma State
Department of Education (OSDE) requires that a licensed supervisor sign the
assessment. Each qualified professional must have a current contract with the
OHCA.
(C)
Documentation
requirements. All psychological services must be documented in the
member's record. All assessment, testing, and treatment services/units billed
must include the following:
(i)
date;
(ii) start and stop time for
each session/unit billed and physical location where service was
provided;
(iii) signature of the
provider;
(iv) credentials of
provider;
(v) specific problem(s),
goals and/or objectives addressed;
(vi) methods used to address problem(s),
goals and objectives;
(vii)
progress made toward goals and objectives;
(viii) patient response to the session or
intervention; and
(ix) any new
problem(s), goals and/or objectives identified during the
session.
(D)
Service Limitations. Testing for a child younger than three (3)
must be medically necessary and meet established child zero (0) to thirty-six
(36) months of age criteria as set forth in the Prior Authorization Manual.
Evaluation and testing is clinically appropriate and allowable when an accurate
diagnosis and determination of treatment needs is needed. Eight (8) hours/units
of testing per patient over the age of three (3), per provider is allowed every
twelve (12) months. There may be instances when further testing is appropriate
based on established medical necessity criteria found in the Prior
Authorization Manual. Justification for additional testing beyond allowed
amount as specified in this Section must be clearly explained and documented in
the medical record. Testing units must be billed on the date the actual
testing, interpretation, scoring, and reporting are performed. A maximum of
twelve (12) hours of therapy and testing, per day per rendering provider are
allowed. A child who is being treated in an acute inpatient setting can receive
separate psychological services by a physician or psychologist as the inpatient
per diem is for "non-physician" services only. A child receiving residential
level treatment in either a therapeutic foster care home, or group home may not
receive additional individual, group or family counseling or psychological
testing unless allowed by the OHCA or its designated agent. Psychologists
employed in state and federal agencies, who are not permitted to engage in
private practice, cannot be reimbursed for services as an individually
contracted provider. For assessment conducted in a school setting the OSDE
requires that a licensed supervisor sign the assessment. For individuals who
qualify for Part B of Medicare, payment is made utilizing the SoonerCare
allowable for comparable services. Payment is made to physicians, LBHPs or
psychologists with a license to practice in the state where the services is
performed or to practitioners who have completed education requirements and are
under current board approved supervision to become
licensed.
Added at 26 Ok Reg 734, eff 4-1-09 (emergency); Added at 26 Ok Reg 2090, eff 6-25-09; Amended at 27 Ok Reg 2386, eff 7-10-10 (emergency); Amended at 28 Ok Reg 1480, eff 6-25-11; Amended at 29 Ok Reg 413, eff 3-7-12 (emergency); Amended at 29 Ok Reg 1125, eff 6-25-12
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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