Current through Vol. 42, No. 1, September 16, 2024
Payment is made for behavioral health targeted case
management services as set forth in this Section. The limitations set forth in
this Section do not apply to case management provided in programs and service
delivery models which are not reimbursed for case management on a
fee-for-service basis.
(1)
Description of behavioral health case management services.
Behavioral health case management services are provided to assist eligible
individuals in gaining access to needed medical, social, educational and other
services essential to meeting basic human needs. Services under behavioral
health targeted case management are not comparable in amount, duration and
scope. The target groups for behavioral health case management services are
persons under age twenty-one (21) who are in imminent risk of out-of-home
placement for psychiatric or substance abuse reasons or are in out-of-home
placement due to psychiatric or substance abuse reasons, and chronically and/or
severely mentally ill adults who are institutionalized or are at risk of
institutionalization. All behavioral health case management services will be
authorized based on established medical necessity criteria.
(A) The behavioral health case manager
provides assessment of case management needs, development of a case management
care plan, referral, linkage, monitoring and advocacy on behalf of the member
to gain access to appropriate community resources. The behavioral health case
manager must monitor the progress in gaining access to services and continued
appropriate utilization of necessary community resources. Behavioral case
management is designed to promote recovery, maintain community tenure, and to
assist individuals in accessing services for themselves following the case
management guidelines established by ODMHSAS. In order to be compensable, the
service must be performed utilizing the Strengths Based model of case
management. This model of case management assists individuals in identifying
and securing the range of resources, both environmental and personal, needed to
live in a normally interdependent way in the community. The focus for the
helping process is on strengths, interests, abilities, knowledge and capacities
of each person, not on their diagnosis, weakness or deficits. The relationship
between the service member and the behavioral health case manager is
characterized by mutuality, collaboration, and partnership. Assistive
activities are designed to occur primarily in the community, but may take place
in the behavioral health case manager's office, if more appropriate.
(B) The provider will coordinate transition
services with the member and family (if applicable) by phone or face to face,
to identify immediate needs for return to home/community no more than
seventy-two (72) hours after notification that the member/family requests case
management services. For members discharging from a higher level of care than
outpatient, the higher level of care facility is responsible for scheduling an
appointment with a case management agency for transition and post discharge
services. The case manager will make contact with the member and family (if
applicable) for transition from the higher level of care other than outpatient
back to the community, within seventy-two (72) hours of discharge, and then
conduct a follow-up appointment/contact within seven (7) days. The case manager
will provide linkage/referral to physicians/medication services, psychotherapy
services, rehabilitation and/or support services as described in the case
management service plan.
(C) Case
managers may also provide crisis diversion (unanticipated, unscheduled
situation requiring supportive assistance, face to face or telephone, to
resolve immediate problems before they become overwhelming and severely impair
the individual's ability to function or maintain in the community) to assist
member(s) from progression to a higher level of care. During the follow-up
phase of these referrals or links, the behavioral health case manager will
provide aggressive outreach if appointments or contacts are missed within two
(2) business days of the missed appointments. Community/home based case
management to assess the needs for services will be scheduled as reflected in
the case management service plan, but not less than one (1) time per month. The
member/parent/guardian has the right to refuse behavioral health case
management and cannot be restricted from other services because of a refusal of
behavioral health case management services.
(D) An eligible member/parent/guardian will
not be restricted and will have the freedom to choose a behavioral health case
management provider as well as providers of other medical care.
(E) In order to ensure that behavioral health
case management services appropriately meet the needs of the member and family
and are not duplicated, behavioral health case management activities will be
provided in accordance with an individualized plan of care.
(F) The individual plan of care must include
general goals and objectives pertinent to the overall recovery of the member's
(and family, if applicable) needs. Progress notes must relate to the individual
plan of care and describe the specific activities to be performed. The
individual plan of care must be developed with participation by, as well as,
reviewed and signed by the member, the parent or guardian [if the member is
under eighteen (18)], the behavioral health case manager, and an LBHP or
licensure candidate as defined in OAC
317:30-5-240.3(a) and
(b).
(G) SoonerCare reimbursable behavioral health
case management services include the following:
(i) Gathering necessary psychological,
educational, medical, and social information for the purpose of individual plan
of care development.
(ii)
Face-to-face meetings with the member and/or the parent/guardian/family member
for the implementation of activities delineated in the individual plan of care.
(iii) Face-to-face meetings with
treatment or service providers, necessary for the implementation of activities
delineated in the individual plan of care.
(iv) Supportive activities such as
non-face-to-face communication with the member and/or parent/guardian/family
member.
(v) Non face-to-face
communication with treatment or service providers necessary for the
implementation of activities delineated in the individual plan of care.
(vi) Monitoring of the individual
plan of care to reassess goals and objectives and assess progress and or
barriers to progress.
(vii) Crisis
diversion (unanticipated, unscheduled situation requiring supportive
assistance, face to face or telephone, to resolve immediate problems before
they become overwhelming and severely impair the individual's ability to
function or maintain in the community) to assist member(s) from progression to
a higher level of care.
(viii)
Behavioral health targeted case management is available to individuals
transitioning from institutions to the community [except individuals who are
inmates of public institutions]. Individuals are considered to be transitioning
to the community during the last thirty (30) consecutive days of a covered
institutional stay. This time is to distinguish case management services that
are not within the scope of the institution's discharge planning activities
from case management required for transitioning individuals with complex,
chronic, medical needs to the community. Transition services provided while the
individual is in the institution are to be claimed as delivered on the day of
discharge from the institution.
(2)
Levels of case management.
(A) Standard case management/resource
coordination services are targeted to adults with serious mental illness or
children with serious emotional disturbance, or who have or are at-risk for
mental disorders, including substance use disorders (SUD), and their families,
who need assistance in accessing, coordination, and monitoring of resources and
services. Services are provided to assess an individual's strengths and meet
needs in order to achieve stability in the community. Standard case managers
have caseloads of thirty (30) to thirty-five (35) members. Standard case
management/resource coordination is limited to twelve (12) units per member per
month. Additional units may be authorized up to twenty-five (25) units per
member per month if medical necessity criteria for transitional case management
are met.
(B) Intensive case
management (ICM) is targeted to adults with serious and persistent mental
illness in PACT programs. To ensure that these intense needs are met, caseloads
are limited to between ten (10) to fifteen (15) members. The ICM shall: be a
certified behavioral health case manager II; have a minimum of two (2) years'
behavioral health case management experience; have crisis diversion experience;
have attended the ODMHSAS six (6) hour ICM training and be available
twenty-four (24) hours a day. ICM is limited to fifty-four (54) units per
member per month.
(C) Wraparound
facilitation case management (WFCM) is targeted to children with significant
mental health conditions being treated in a System of Care (SOC) Network who
are deemed at imminent risk of out-of-home placement due to psychiatric or SUD
reasons and in need of more intensive case management services. It is designed
to ensure access to community agencies, services, and people whose functions
are to provide the support, training and assistance required for a stable,
safe, and healthy community life, and decreased need for higher levels of care.
To produce a high fidelity wraparound process, a facilitator can facilitate
between eight (8) and ten (10) families. Staff providing WFCM must meet the
requirements for the SOC/WFCM. WFCM is limited to fifty-four (54) units per
member per month.
(3)
Excluded services. SoonerCare reimbursable behavioral health case
management does not include the following activities:
(A) Physically escorting or transporting a
member or family to scheduled appointments or staying with the member during an
appointment;
(B) Managing
finances;
(C) Providing specific
services such as shopping or paying bills;
(D) Delivering bus tickets, food stamps,
money, etc.;
(E) Counseling,
rehabilitative services, psychiatric assessment, or discharge planning;
(F) Filling out forms,
applications, etc., on behalf of the member when the member is not present;
(G) Filling out SoonerCare forms,
applications, etc.;
(H) Mentoring
or tutoring;
(I) Provision of
behavioral health case management services to the same family by two (2)
separate behavioral health case management agencies;
(J) Non-face-to-face time spent preparing the
assessment document and the service plan paperwork;
(K) Monitoring financial goals;
(L) Leaving voice or text messages for
clients and other failed communication attempts.
(4)
Excluded individuals. The
following SoonerCare members who are receiving similar services through another
method are not eligible for behavioral health case management services without
special arrangements with the Oklahoma Department of Human Services (OKDHS),
OJA, OHCA or ODMHSAS as applicable, in order to avoid duplication in payment.
Services/programs include, but may not be limited to:
(A) Members/families (when applicable) for
whom at-risk case management services are available through OKDHS and OJA
staff;
(B) Members in out-of-home
placement and receiving targeted case management services through staff in a
foster care or group home setting, unless transitioning into the community;
(C) Residents of ICF/IIDs and
nursing facilities unless transitioning into the community;
(D) Members receiving targeted case
management services under a Home and Community Based Services (HCBS) waiver
program;
(E) Members receiving
case management through the ADvantage waiver program;
(F) Members receiving targeted case
management available through a Certified Community Behavioral Health Center
(CCBHC);
(G) Members receiving
case management services through Programs of All-Inclusive Care for the Elderly
(PACE);
(H) Members receiving
Early Intervention case management (EICM);
(I) Members receiving case management
services through certified school-based targeted case management (SBTCM)
providers;
(J) Members receiving
partial hospitalization services; or
(K) Members receiving MST.
(5)
Filing
requirements. Case management services provided to Medicare eligible
members should be filed directly with the fiscal agent.
(6)
Documentation requirements.
The service plan must include general goals and objectives pertinent to the
overall recovery needs of the member. Progress notes must relate to the service
plan and describe the specific activities performed. Behavioral health case
management service plan development is compensable time if the time is spent
communicating with the member and it must be reviewed and signed by the member,
the behavioral health case manager, and an LBHP or licensure candidate as
defined at OAC
317:30-5-240.3(a) and
(b). All behavioral health case management
services rendered must be reflected by documentation in the records. In
addition to a complete behavioral health case management service, plan
documentation of each session must include but is not limited to:
(A) Date;
(B) Person(s) to whom services are rendered;
(C) Start and stop times for each
service;
(D) Original signature or
the service provider [original signatures for faxed items must be added to the
clinical file within thirty (30) days];
(E) Credentials of the service provider;
(F) Specific service plan needs,
goals, and/or objectives addressed;
(G) Specific activities performed by the
behavioral health case manager on behalf of the member related to advocacy,
linkage, referral, or monitoring used to address needs, goals, and/or
objectives;
(H) Progress and
barriers made towards goals, and/or objectives;
(I) Member/family (when applicable) response
to the service;
(J) Any new
service plan needs, goals, and/or objectives identified during the service; and
(K) Member satisfaction with staff
intervention.
(7)
Case management travel time. The rate for case management services
assumes that the case manager will spend some amount of time traveling to the
member for the face-to-face service. The case manager must only bill for the
actual face-to-face time that they spend with the member and not bill for
travel time. This would be considered duplicative billing since the rate
assumes the travel component already.
