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 317:30-5-241.3 - Behavioral Health Rehabilitation (BHR) services
Universal Citation: OK Admin Code 317:30-5-241.3
Current through Vol. 42, No. 1, September 16, 2024
(a) Definition. Behavioral Health Rehabilitation (BHR) services are goal oriented outpatient interventions that target the maximum reduction of mental and/or behavioral health impairments and strive to restore the members to their best possible mental and/or behavioral health functioning. BHR services must be coordinated in a manner that is in the best interest of the member and may be provided in a variety of community and/or professional settings that protect and assure confidentiality. For purposes of this Section, BHR includes Psychosocial Rehabilitation, Outpatient Substance Abuse Rehabilitation, and Medication Training and Support.
(b) Psychosocial Rehabilitation (PSR).
(1)
Definition. PSR services are
face-to-face Behavioral Health Rehabilitation services which are necessary to
improve the member's ability to function in the community. They are performed
to improve the skills and abilities of members to live interdependently in the
community, improve self-care and social skills, and promote lifestyle change
and recovery practices. Rehabilitation services may be provided individually or
in group sessions, and they take the format of curriculum based education and
skills training.
(2)
Clinical
restrictions. This service is generally performed with only the members
and the qualified provider, but may include a member and the member's
family/support system when providing educational services from a curriculum
that focuses on the member's diagnosis, symptom management, and recovery. A
member who at the time of service is not able to cognitively benefit from the
treatment due to active hallucinations, substance abuse, or other impairments
is not suitable for this service. Family involvement is allowed for support of
the member and education regarding his/her recovery, but does not constitute
family therapy, which requires a licensed provider.
(3)
Qualified practitioners. A
Certified Behavioral Health Case Manager II (CM II), CADC, LBHP , or Licensure
Candidate may perform PSR, following development of a service plan and
treatment curriculum approved by an LBHP or Licensure Candidate. The CM II and
CADC must have immediate access to a LBHP who can provide clinical oversight
and collaborate with the qualified PSR provider in the provision of services. A
minimum of one monthly face-to-face consultation with a LBHP is required for
PSR providers . In addition, a minimum of one face-to-face consultation per
week with a LBHP or Licensure Candidateis required for PSR providers regularly
rendering services away from the outpatient behavioral health agency
site.
(4)
Group sizes.
The maximum staffing ratio is fourteen members for each qualified provider for
adults and eight to one for children under the age of eighteen.
(5)
Limitations.
(A)
Transportation. Travel time
to and from PSR treatment is not compensable. Group PSR services do not qualify
for the OHCA transportation program, but OHCA will arrange for transportation
for those who require specialized transportation equipment.
(B)
Time. Breaks, lunchtime and
times when the member is unable or unwilling to participate are not compensable
and must be deducted from the overall billed time.
(C)
Location. In order to
develop and improve the member's community and interpersonal functioning and
self care abilities, PSR services may take place in settings away from the
outpatient behavioral health agency site as long as the setting protects and
assures confidentiality. When this occurs, the qualified provider must be
present and interacting, teaching, or supporting the defined learning
objectives of the member for the entire claimed time.
(D)
Eligibility for PSR
services. All PSR services require prior authorization and must meet
established medical necessity criteria.
(i)
Adults. PSR services for adults are limited to members who have a
history of psychiatric hospitalization or admissions to crisis centers, have
been determined disabled by the SSA for mental health reasons, are residing in
residential care facilities or are receiving services through a specialty court
program.
(ii)
Children. PSR services for children are limited to members who
have a history of psychiatric hospitalization or admissions to crisis centers;
have been determined disabled by the SSA for mental health reasons; have a
current Individual Education Plan (IEP) or 504 Plan for emotional disturbance;
or have been evaluated by a school psychologist, licensed psychologist or
psychiatrist and determined to be "at risk" as outlined in the Prior
Authorization Manual.
(iii) The
following members are not eligible for PSR services:
(I) Residents of ICF/IID facilities, unless
authorized by OHCA or its designated agent;
(II) children under age 6, unless a prior
authorization for children ages 4 and 5 has been granted by OHCA or its
designated agent based on the criteria in (5)(D)(ii) above as well as a finding
of medical necessity;
(III)
children receiving RBMS in a group home or therapeutic foster home, unless
authorized by OHCA or its designated agent;
(IV) inmates of public
institutions;
(V) members residing
in inpatient hospitals or IMDs; and
(VI) members residing in nursing
facilities.
(E)
Billing limits. PSR services
are time-limited services designed to be provided over the briefest and most
effective period possible and as adjunct (enhancing) interventions to
compliment more intensive behavioral health therapies. Service limits are based
on the member's needs according to the CAR or other approved tool, the
requested placement based on the level of functioning rating, medical
necessity, and best practice. Service limitations are designed to help prevent
rehabilitation diminishing return by remaining within reasonable age and
developmentally appropriate daily limits. PSR services authorized under this
Section are separate and distinct from, but should not duplicate the structured
services required for children residing in group home or therapeutic foster
care settings, or receiving services in Day Treatment or Partial
Hospitalization Programs. Children under an ODMHSAS Systems of Care program and
adults residing in residential care facilities may be prior authorized
additional units as part of an intensive transition period. PSR is billed in
unit increments of 15 minutes with the following limits:
(i)
Group PSR. The maximum is 24
units per day for adults and 16 units per day for children.
(ii)
Individual PSR. The maximum
is six units per day.
(iii)
Per-Member service levels and limits. Unless otherwise specified,
group and/or individual PSR services provided in combination may not exceed the
monthly limits established in the individual's prior authorization. Limits on
PSR services are established based on the level for which the member has been
approved.
(iv)
EPSDT.
Pursuant to OAC
317:30-3-65
et seq., billing limits may be exceeded or may not apply if documentation
demonstrates that the requested services are medically necessary and are needed
to correct or ameliorate defects, physical or behavioral illnesses or
conditions discovered through a screening tool approved by OHCA or its
designated agent. The OHCA has produced forms for documenting an EPSDT child
health checkup screening which the provider can access on the OHCA
website.
(F)
Progress Notes. In accordance with OAC
317:30-5-241.1,
the behavioral health service plan developed by the LBHP or Licensure Candidate
must include 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. When PSR services are prescribed,
the plan must address objectives that are specific, attainable, realistic, and
time-limited. The plan must include the appropriate treatment coordination to
achieve the maximum reduction of the mental and/or behavioral health disability
and to restore the member to their best possible functional level. Progress
notes for PSR day programs must be documented in accordance with the
requirements found in
317:30-5-248(5).
Progress notes for all other Behavioral Health Rehabilitation services must be
documented in accordance with the requirements found in
317:30-5-248(3).
(G)
Additional documentation
requirements.
(i) a list/log/sign in
sheet of participants for each Group rehabilitative session and facilitating
qualified provider must be maintained; and
(ii) Documentation of ongoing consultation
and/or collaboration with an LBHP or Licensure Candidate related to the
provision of PSR services.
(H)
Non-Covered Services. The
following services are not considered BHR and are not reimbursable:
(i) Room and board;
(ii) educational costs;
(iii) supported employment; and
(iv) respite.
(c) Outpatient Substance Abuse Rehabilitation Services.
(1)
Definition. Covered outpatient substance abuse rehabilitation
services are provided in non-residential settings in regularly scheduled
sessions intended for individuals not requiring a more intensive level of care
or those who require continuing services following more intensive treatment
regimes. The purpose of substance abuse rehabilitation services is to begin,
maintain, and/or enhance recovery from alcoholism, problem drinking, drug
abuse, drug dependency addiction or nicotine use and addiction. Rehabilitation
services may be provided individually or in group sessions, and they take the
format of curriculum based education and skills training.
(2)
Limitations. Group sessions
may not be provided in the home.
(3)
Eligibility. Members
eligible for substance abuse rehabilitation services must meet the criteria for
ASAM PCC Treatment Level 1, Outpatient Treatment.
(4)
Qualified practitioners. CM
II, CADC , LBHP or Licensure Candidate.
(5)
Billing limits. Group
rehabilitation is limited to two (2) hours per session. Group and/or individual
outpatient substance abuse rehabilitation services provided in combination may
not exceed the monthly limits established in the individual's prior
authorization. Limits on services are established based on the level for which
the member has been approved. There are no limits on substance abuse
rehabilitation services for individuals determined to be Level 4.
(6)
Documentation requirements.
Documentation requirements are the same as for PSR services as set forth in
30-5-241.3(b)(5)(F).
(d) Medication training and support.
(1)
Definition. Medication
Training and Support is a documented review and educational session by a
registered nurse, advanced practice nurse, or physician assistant focusing on a
member's response to medication and compliance with the medication regimen. The
review must include an assessment of medication compliance and medication side
effects. Vital signs must be taken including pulse, blood pressure and
respiration and documented within the medical or clinical record. A physician
is not required to be present, but must be available for consult. Medication
Training and Support is designed to maintain the member on the appropriate
level of the least intrusive medications, encourage normalization and prevent
hospitalization.
(2)
Limitations.
(A) Medication
Training and Support may not be billed for SoonerCare members who reside in
ICF/IID facilities.
(B) Two units
are allowed per month per patient.
(C) Medication Training & Support is not
allowed to be billed on the same day as an evaluation and management (E/M)
service provided by a psychiatrist.
(3)
Qualified professionals.
Must be provided by a licensed registered nurse, an advanced practice nurse, or
a physician assistant as a direct service under the supervision of a
physician.
(4)
Documentation
requirements. Medication Training and Support documented review must
focus on:
(A) a member's response to
medication;
(B) compliance with the
medication regimen;
(C) medication
benefits and side effects;
(D)
vital signs, which include pulse, blood pressure and respiration; and
(E) documented within the progress
notes/medication record.
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 305, eff 11-3-09 (emergency); Amended at 27 Ok Reg 966, eff 5-13-10 ; Added at 27 Ok Reg 2753, eff 7-20-10 (emergency); Added at 28 Ok Reg 1469, 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 ; Amended at 30 Ok Reg 331, eff 1-14-13 (emergency); Amended at 30 Ok Reg 1146, eff 7-1-13
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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