Current through Vol. 41, No. 20, July 1, 2024
(a)
Outpatient Behavioral Health Services. Outpatient behavioral
health services are covered as set forth in this Section, and when provided in
accordance with a documented individualized service plan and/or medical record,
developed to treat the identified behavioral health and/or substance use
disorder(s), unless specified otherwise.
(1)
All services are to be for the goal of improvement of functioning,
independence, or wellbeing of the member. The services and treatment plans are
to be recovery focused, trauma and co-occurring specific. The member must be
able to actively participate in the treatment. Active participation means that
the member must have sufficient cognitive abilities, communication skills, and
short-term memory to derive a reasonable benefit from the treatment.
(2) In order to be reimbursed for services,
providers must submit a completed Customer Data Core (CDC) to OHCA or its
designated agent. The CDC must be reviewed, updated and resubmitted by the
provider every six (6) months. Reimbursement is made only for services provided
while a current CDC is on file with OHCA or its designated agent. For further
information and instructions regarding the CDC, refer to the Prior
Authorization Manual.
(3) Some
outpatient behavioral health services may require authorization. For
information regarding services requiring authorization and the process for
obtaining them, refer to the Prior Authorization Manual. Authorization of
services is not a guarantee of payment. The provider is responsible for
ensuring that the eligibility, medical necessity, procedural, coding, claims
submission, and all other state and federal requirements are met. OHCA does
retain the final administrative review over both authorization and review of
services as required by
42 CFR
431.10.
(b)
Adults. Outpatient
behavioral health coverage for adults rendered by aLBHP is limited to
bio-psycho-social assessments when required by OHCA as part of a preoperative
prior authorization protocol for organ transplant or bariatric surgical
procedures.
(1) The interview and assessment
is defined as a face-to-face interaction with the member. Assessment includes a
history, mental status, full bio-psycho-social evaluation, a disposition,
communications with family or other sources, review of laboratory or other
pertinent medical information, and medical/clinical consultations as necessary.
The pre-op evaluation should aim to assess the member's psychological
well-being, ability to make informed decisions, and willingness to participate
actively in postoperative treatment.
(2) For bariatric preoperative assessments,
issues to address include, but are not limited to: depression, self-esteem,
stress management, coping skills, binge eating, change in eating habits, other
eating disorders, change in social roles, changes associated with return to
work/school, body image, sexual function, lifestyle issues, personality factors
that may affect treatment and recovery, alcohol or substance use disorders,
ability to make lasting behavior changes, and need for further support and
counseling.
(c)
Children. Coverage for children includes the following services:
(1) Bio-psycho-social and level of care
assessments.
(A) The interview and assessment
is defined as a face-to-face interaction with the member. Assessment includes a
history, mental status, full bio-psycho-social evaluation, a disposition,
communications with family or other sources, review of laboratory or other
pertinent medical information, and medical/clinical consultations as necessary.
(B) Assessments for children's
level of care determination of medical necessity must follow a specified
assessment process through OHCA or their designated agent. Only one assessment
is allowable per provider per member. If there has been a break in service over
a six (6) month period, or the assessment is conducted for the purpose of
determining a child's need for inpatient psychiatric admission, then an
additional unit can be authorized by OHCA, or their designated agent.
(2) Psychotherapy in an
outpatient setting including an office, clinic, or other confidential setting.
The services may be performed at the residence of the member if it is
demonstrated that it is clinically beneficial, or if the member is unable to go
to a clinic or office. Individual psychotherapy is defined as a one to one
treatment using a widely accepted modality or treatment framework suited to the
individual's age, developmental abilities and diagnosis. It may include
specialized techniques such as biofeedback or hypnosis. Psychotherapy is
considered to involve "interactive complexity" when there are communication
factors during a visit that complicate delivery of the psychotherapy by the
LBHP. Sessions typically involve members who have other individuals legally
responsible for their care (i.e. minors or adults with guardians); members who
request others to be involved in their care during the session (i.e. adults
accompanied by one or more participating family members or interpreter or
language translator); or members that require involvement of other third
parties (i.e. child welfare, juvenile justice, parole/probation officers,
schools, etc.). Psychotherapy should only be reported as involving interactive
complexity when at least one of the following communication factors is present:
(A) The need to manage maladaptive
communication (i.e. related to high anxiety, high reactivity, repeated
questions, or disagreement) among participants that complicate delivery of
care.
(B) Caregiver
emotions/behavior that interfere with implementation of the treatment plan.
(C) Evidence/disclosure of a
sentinel event and mandated report to a third party (i.e. abuse or neglect with
report to state agency) with initiation of discussion of the sentinel event
and/or report with patient and other visit participants.
(D) Use of play equipment, physical devices,
interpreter or translator to overcome barriers to therapeutic interaction with
a patient who is not fluent in the same language or who has not developed or
lost expressive or receptive language skills to use or understand typical
language.
(3) Family
Psychotherapy is performed in an outpatient setting limited to an office,
clinic, or other confidential setting. Family therapy is a face-to-face
interaction between a therapist and the patient/family to facilitate emotional,
psychological or behavioral changes and promote communication and
understanding. Family therapy must be provided for the benefit of the member as
a specifically identified component of an individual treatment plan.
(4) Group and/or Interactive Group
psychotherapy in an outpatient setting must be performed in an office, clinic,
or other confidential setting. Group therapy is a face-to-face interaction
between a therapist and two or more unrelated patients (though there may be
siblings in the same group, just not siblings only) to facilitate emotional,
psychological, or behavioral changes. All group therapy records must indicate
group size. Maximum total group size is six (6) for ages four (4) up to
eighteen (18) . Groups 18-20 year olds can include eight (8) individuals. Group
therapy must be provided for the benefit of the member as a specifically
identified component of an individual treatment plan. Multi-family group
therapy size is limited to eight (8) family units.
(5) Assessment/evaluation and testing is
provided by a psychologist, certified psychometrist, psychological technician
of a psychologist or a LBHP utilizing tests selected from currently accepted
assessment test batteries. For assessments conducted in a school setting, the
Oklahoma State Department of Education requires that a licensed supervisor sign
the assessment. 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. Test results must be
reflected in the service plan or medical record. The service plan must clearly
document the need for the testing and what the testing is expected to achieve.
Testing units must be billed on the date the testing, interpretation, scoring,
and/or reporting was performed and supported by documentation.
(6) Crisis intervention services for the
purpose of stabilization and hospitalization diversion as clinically
appropriate.
(7) Payment for
therapy services provided by a LBHP to any one member is limited to four (4)
sessions/units per month. A maximum of twelve (12) sessions/units of therapy
and testing services per day per provider are allowed. A maximum of thirty-five
(35) hours of therapy per week per provider are allowed. The weekly service
hour limitation will be calculated using a rolling four (4) week average. Case
Management services are considered an integral component of the behavioral
health services listed above.
(8)
A child receiving residential behavioral management in a foster home, also
known as therapeutic foster care, or a child receiving residential behavioral
management in a group home, also known as therapeutic group home, may not
receive individual, group or family counseling or testing unless allowed by the
OHCA or their designated agent.
(d)
Home and Community Based Waiver
Services for the Intellectually Disabled. All providers participating in
the Home and Community Based Waiver Services for the intellectually disabled
program must have a separate contract with this Authority to provide services
under this program. All services are specified in the individual's plan of
care.
(e)
Individuals
eligible for Part B of Medicare. Payment is made utilizing the Medicaid
allowable for comparable services.
(f)
Nursing Facilities. Services
provided to members residing in nursing facilities may not be billed to
SoonerCare.
Added at 27 Ok Reg 1676, eff 7-10-10 (emergency) ; Added
at 28 Ok Reg 1483, 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
1146, eff 7-1-13