How can I bill my claims? The Provider Agency and Recovery Manager shall utilize CMBHS to submit service encounters IRPs and Medicaid claims when CMBHS is made available..
How can I bill my claims? The Provider Agency and Recovery Manager shall utilize CMBHS to submit service encounters IRPs and Medicaid claims when CMBHS is made available.
policy and procedure for HOME AND COMMUNITY BASED SERVICES -ADULT MENTAL HEALTH
Diadem Hearts INC
The Department of State Health Services is seeking more information from your organization to verify you meet the requirements specified in the Home and Community Based Services-Adult Mental Health Open Enrollment (OE).
Our findings indicate your application remains incomplete. Applicant needs to ensure that they have both a policy and procedure in place for all the items notated in the Open Enrollment.
Below you will find some useful information to help you format the content of your policies and procedures. Also please see attached template for an example of how to format your policies and procedures.
Policies are your rules and guidelines that ensure consistency and compliance with the HCBS-AMH program
Your HCBS-AMH Policies should address:
what the Policy is
who is responsible for the execution and enforcement of the Policy and
why the Policy is required.
Procedures define the specific instructions necessary to perform a task or part of a Process.
Your HCBS-AMH Procedures should detail:
who performs the Procedure
what steps are performed
when the steps are performed and
how the Procedure is performed.
*DSHS has provided feedback and questions below outlining some of the deficits in your application:
Update on the HCBS-AMH program: The 84th Legislature directed DSHS to expand HCBS-AMH to divert populations with serious mental illness (SMI) from jails and emergency departments (ED) into community treatment programs. Providers that contract with DSHS are now able to choose which population(s) they serve.
} Long-term psychiatric hospitalization
} Jail Diversion
} Emergency Department Diversion
For an individual to qualify to receive a referral into the program they must meet 1 of the 3 criteria below:
1. For Jail Diversion:
During the three years prior to their referral an individual must have:
o two or more psychiatric crises (i.e. inpatient psychiatric hospitalizations and/or crisis episodes requiring outpatient mental health treatment) and
o repeated discharges from correctional facilities (i.e. three or more).
2. For Emergency Department Diversion:
During the three years prior to their referral an individual must have:
o a history of inpatient psychiatric hospitalizations or outpatient mental health crisis episodes and
o a pattern of frequent utilization of the emergency department (ED) (i.e. fifteen or more total ED visits)
3. For Long-term Hospitalization
During the five years prior to their referral an individual must have:
o Spent three or more cumulative or consecutive years in an inpatient psychiatric setting
Questions for your response:
Please identify the population(s) you intend on serving? (Extended tenure Frequent arrests Frequent ED visits)
How long have you been a provider of mental health services?-THIS IS MY FIRST CONTRACT i HAVE NEVER BEEN A PROVIDER BUT HAVE WORKED IN MENTAL HOSPITAL
What types of services do you currently provide?
Tell me about your experience working with individuals with mental healthcare needs?
Capacity to serve How many individuals do you anticipate being able to serve? This can be determined based on the number of staff you employ or intend to employ for each service area broken down by direct employees and sub-contractors.
This is the Link to the Provider Manual: provider manual
Please submit the following items:
Please submit policy and procedures as outlined in the provider manual (Form L) for provision of services utilization management housing and placement
Please submit detailed job descriptions for each position with required qualifications. Refer to the Provider Manual sections 9200 and 9300 Job descriptions should be provided for every service type included in our program services
Please submit an updated organizational chart that includes direct care staff contractors and subcontractors
Please submit policy and procedures on provision of services/ coordination of care including routine and emergency availability assurance that all services will be provided and notification to DSHS if services are unavailable
Please expand on policy and procedures to include credentialing and staff training for both direct staff and subcontractors verification of staff licensure qualifications training requirements and certification records
Provide policy for Personnel Recordkeeping Policy and Procedure needs to outline the applications/tools you will use to verify the following:
Review of Medicare/Medicaid Sanctions for staff members
Maintaining documentation verifying malpractice or liability insurance for professional staff.
Verify license of staff members
Review of state regulation sanctions of staff members (i.e. Employee Misconduct or Office of Inspector General)
Review disciplinary actions against staff members (i.e. State Board or other agency)
How you ensure criminal history and background checks are completed for all staff involved in the administration of HCBS-AMH services
Need to include your credentialing procedure including applications used to verify credentials.
Provide policy and procedures for documenting training on policy and procedures for all staff and subcontractors
o Need to identify how you will document and monitor training to ensure all employees are trained according to HCBS-AMH standards.
Provide Policy and Procedures that outline how you will document staff training is in compliance with HCBS-AMH requirements (see Appendix A in Provider Manual for an outline of required HCBS-AMH trainings)
o Need to identify in the document which trainings each service provider will need to receive.
o Identify how you will monitor that all staff trainings are up to date.
Provide policy and procedures for maintaining client record keeping practices including the retention of records updated and signed IRP updated and signed progress notes (Provider Manual section 13400)
Expand on and include in policy and procedures on confidentiality of client records and progress notes
o Expand your procedures for ensuring confidentiality of client records and progress notes.
More details needed so any employee reading the policy understands the specifics of HIPPA policy.
Please provide policy and procedures for medication safety
Provide policy and procedure on how to inform clients of rights and responsibilities and organizational grievance procedures
o Consumer grievancesPlease clarify this section.
o Client complaints how does your facility gather and address client complaints?
Provide policy and procedures for Medicaid fair hearing
Provide policy and procedures for personnel and client safety (examples include PMAB or CIT)
Expand on critical incident reporting and reporting procedures for reporting abuse neglect and exploitation based on information in provider manual (Provider Manual section 13500)
Provide separate contraband policy and procedures that outlines how discoveries of illicit drugs or weapons will be handled
Elaborate on minimum standards identified in provider manual on procedures for seclusion and restraint and how staff will receive initial and ongoing training on the use of restraints
Provide policy and procedures on how employees and subcontractors will receive payment for services rendered
o Payment of employees and subcontractors A payroll policy defines the responsibilities and accountabilities of payroll staff and managers. Since payroll involves confidential information the policy must specify access and security levels. The payroll procedures detail the process from when the employee is hired. They include payroll activities and forms required for processing new hires employment changes information updates special payments deductions time reporting and termination
Payroll department responsibilities
Title of position that is in charge of managing payroll
Time Reporting how do employees document time
How employees receive paychecks
Payroll schedules and deadlines for submission of payroll documents
Provide policy and procedures for the transfer of individuals to another HCBS-AMH provider (Provider Manual section 10300)
Provide policy and procedures for the discharge of individuals from HCBS-AMH (Provider Manual section 10000)
Provide policy and procedures for a quality management plan including the formal process to diagnose problems and tracking resolution and monitoring for improvement
o Quality Management Plan
Formal procedures for diagnosis of problems Note: This procedure should exist to help diagnose problems that exist within providing HCBS-AMH services not diagnosing individual client problems.
Tracking resolution; and
Monitoring for improvement
Provide policy and procedures for utilization management (Provider Manual section 12000)
Provide policy and procedure for monitoring and tracking placement expansion of community housing relationship plan. Reference form H of the OE
Provide policy and procedures verifying provider owned and operated settings meet setting requirements. Policy should outline procedures for Form H (Provider Manual section 11000)
These are important links please look at the links
you can access our Open Enrollment applications on our webpage at http://www.dshs.state.tx.us/mhsa/hcbs-amh/.
i AM ALSO PASTING SOME FREQUENTLY ASKED QUESTIONS. YOU MAY FIND ANSWERS TO SOME QUESTIONS IN THE POLICY AND PROCEDURES Frequently-Asked Questions FAQs 1. Why was the decision made to do a State Plan Amendment 1915(i) rather than a 1915(c) Medicaid waiver? The decision to seek a SPA rather than a waiver was made because HCBS waivers would generally require that the person qualify medically for a nursing home or Intermediate Care Facility (ICF) IDD. This would exclude the target population of the program (individuals who no longer require an institutional level of care). The 1915(i) SPA allows the state to develop its own needs based criteria appropriate to the population served. 1915(c) waivers require that the individual meet a level of care for a Medicaid qualified institutional setting; Institutions of Mental Disease for people between 21 and 65 are not a qualified institutional setting under Medicaid. A 1915(c) waiver would exclude a majority of the target population for the program who are between the ages of 21 and 65. 2. Are HCBS-AMH services billed as fee-for-service? Yes HCBS-AMH enrollees are served through a fee-for-service delivery system where providers arepaid for each service. Rates are posted at Health and Human Services Commissions website at http://www.hhsc.state.tx.us/rad/long-term-svcs/amh/index.shtml 3. What is the maximum income level for participants to be eligible for the HCBS-AMH program? Individuals receiving HCBS-AMH services must have income that does not exceed 150% of the Federal Poverty Line. 4. Are HCBS-AMH Service Providers and Recovery Managers guaranteed a certain number of enrolled participants? HCBS-AMH Providers and Recovery Managers are selected by the individual receiving services therefore DSHS is unable to guarantee a certain number of participants. 5. Are the HCBS-AMH Service Providers and Recovery Managers required to go through any special training? The Training requirements can be viewed in the Provider Manual Appendix A located at http://www.dshs.state.tx.us/mhsa/hcbs-amh/documents/ 6. Can the same agency apply for both the Recovery Management and Service Provider Open Enrollments (OEs)? Yes the same agency can apply for both OEs. However that agency cant provide both service components (Recovery management and services) to the same individual. CMS mandates that the Recovery Manager must be a separate entity from the HCBS-AMH service provider. HCBS-AMH Recovery Management Entities may not be a Provider of other HCBS-AMH services listed on the individuals IRP unless the HCBS-AMH Recovery Management Entity is the only willing and qualified entity in a geographic area where the individual chooses to receive the services. This policy/procedure is subject to change upon CMSs final approval of the State Plan Amendment (SPA). 7. How can I bill my claims? The Provider Agency and Recovery Manager shall utilize CMBHS to submit service encounters IRPs and Medicaid claims when CMBHS is made available. Until such time that CMBHS has the capacity tosupport these functions submission of this information will be submitted as otherwise outlined below: The HCBS-AMH Provider willemail the HCBS-AMH Invoicing Template to DSHS via encryptedmail. The Invoicing Template shall be submitted no later than 5:00 pm (Central Standard Time) 15 calendar days after the last day of the following month. The time period for services is as follows: The 1st day of the month through the last day of the month. 8. How were billing rates set? HHSC held a rate hearing on March 3 2014 to gain input from potential providers in order to ensure the rates were set appropriately and correspond to the intensity of the provision services required to meet the needs of the individual.Payment rates for HCBS-AMH services were developed based onpayment rates determined for other programs that provide similar services. 9. Will there be an overall cap for HCBS-AMH services? There will not be a cap for billing HCBS-AMH services. Cost neutrality does not have to be demonstrated in this program. DSHS will have final approval of the IRP and all billing invoices. 10. Will individuals be eligible to participate in the program if they are on parole or probation? As long as the individual is not an inmate of the criminal justice system they are able to participate in the HCBS-AMH program. 11. Who can refer an individual for the HCBS-AMH program? An individual can be referred by an LMHA or by a state hospital. 12. How is an individual determined eligible for the HCBS-AMH program? Individuals must meet the following initial criteria in order to be eligible for HCBS-AMH: Diagnosis of serious mental illness (SMI); Extended tenure (three or more cumulative years) in an inpatient psychiatric hospital during thefive years prior to enrollment; Individual is not accessing these services by any other means including enrollment in Long-term Services and Supports (LTSS) Community Living Assistance andSupport Services (CLASS) Deaf Blind with Multiple Disabilities (DBMD) Home and Community-based Services Waiver (HCS) or Texas Home Living Waiver (TxHml) or STAR+PLUS HCBS Waiver. In addition to meeting initial eligibility criteria HCBS-AMH eligibility is determined using demographic clinical functional and financial criteria. Individuals are assessed using the HCBS-AMH Uniform Assessment. 13. Are QMB and CBA HCBS programs that individuals cannot be dually enrolled in? Individuals enrolled in QMB would not qualify for the traditional Medicaid-funded HCBS AMH program since they are not Medicaid eligible. However they could qualify for HCBS-AMH as a non-Medicaid participant using general revenue if funding permits. If this individual is enrolled as a non-Medicaid participant their enrollment in QMB may impact providers when claiming for some services. Community based Alternatives (CBA) has been replaced by the STAR+PLUS Home and Community-based Services (HCBS) waiver. The STAR+PLUS Home and Community-based Services (HCBS) waiver is a HCBS program and the individual could not be dually enrolled. 14. If an individual enrolled in HCBS-AMH required a CNA what service would that be billed under? CNA services would fall under Personal Assistance Services (PAS). PAS services fall under Acute Care Services which will be provided thru the MCO. 15. What does the * on the billing rates mean? Tied to the Acute Care code in the applicable Texas Medicaid Fee Schedule located on the Texas Medicaid & Healthcare Partnership (TMHP) website (see Fee Schedules). 16. Does HCBS-AMH Adaptive Aids service cover Applications for individuals phones to assist with medication reminders and other prompts to assist in independent living? Yes applications for individualsphone will be covered in Adaptive Aids. 17. PeerSupport: What is the current rate based on? Can PeerSupport be billed for a group? Why is the rate lower than Rehabilitation? The current rate for peersupport is based on a rates hearing HHSC held on March 3 2014 to gain input from potential providers in order to ensure the rates were set appropriately and correspond to the intensity of the provision services required to meet the needs of the individual. PeerSupport cant be billed for a group. The peersupport services in the HCBS-AMH program are designed to provide advocacy and foster recovery-oriented skills to help an individual enhance their recovery. In the HCBS-AMH program peersupport is considered different than psychosocial rehabilitation in the HCBS-AMH program. Because of this the educational requirements required for HCBS-AMH peer supports differ than those requirements for HCBS-AMH providers of psychosocial rehabilitation. Instead the educational requirements for peersupport are in line with those requirements for paraprofessionals and the service rates were based off the service rates for a paraprofessional. 18. Is STAR+PLUS state wide in Texas? Why is the HCBS-AMH target population mostly eligible to receive services from a STAR+PLUS MCO? Yes as of September 1 2014 STAR + PLUS was available statewide. The HCBS-AMH target population will mostly be enrolled in STAR + PLUS MCO because they meetone of the following criteria: Have a disability and qualify for Supplemental Security Income (SSI) or Medicaid because of low income Qualify for Medicaid because they receive STAR+PLUS Home and Community Based Services (HCBS) waiver services Are not dually eligible and are receiving services throughone of thefive DADS programs for individuals with intellectual and developmental disabilities (IDD) 19. Will the provider offer all services including recovery management? HCBS-AMH hastwo separate providers the Service Provider and Recovery Manager. The Service Provider will provide all services offered within the program except Recovery Management. Recovery Management will be a separate independent provider. That being said the same agency can apply for both OEs. However that agency cant provide both service components (Recovery management and services) to the same individual. CMS mandates that the Recovery Manager must be a separate entity from the HCBS-AMH service provider. HCBS-AMH Recovery Management Entities may not be a Provider of other HCBS-AMH services listed on the individuals IRP unless the HCBS-AMH Recovery Management Entity is the only willing and qualified entity in a geographic area where the individual chooses to receive the services. This policy/procedure is subject to change upon CMSs final approval of the State Plan Amendment (SPA). 20. What kind of QM surveys will be involved in being a provider or recovery management organization? The HCBS-AMH QM Plan is available on our webpage at http://www.dshs.state.tx.us/mhsa/hcbs-amh/. Also review Section 15000 of the Provider Manual which is also available on the webpage. 21. Has the IRP forms been developed or will each provider and recovery manager create their own? The IRP template has been developed with input from Via Hope. The IRP template is included in the Provider Manual which is currently accessible online at the HCBS-AMH website. 22. In the unlikely event that a provider is unable to provide the necessary/authorized services or goes out of business unexpectedly who is responsible for filling that gap and providing the necessary services? The Recovery Manager will work closely with the individual to help them select a new provider of services. 23. What is frequency and expectation of interaction with the MCO? It is expected that the MCO service coordinator will participate in weeklyphone calls with the Recovery Manager and HCBS-AMH providers. 24. What if I have questions about the open enrollments? All procurement related questions should be referred to Procurement and Contract Services (PCS). Questions concerning requirements relating to the dates of submission and the completion of required forms should be forwarded to PCS at firstname.lastname@example.org. 25. What work has been done to ensure there is housing availability? Are housing vouchers available? DSHS has been working closely with TDHCA to ensure the HCBS-AMH target population will be eligible to participate in Section 811 and Project Access. Additionally DSHS is currently working with community providers and different opportunities to expand housing opportunities. 26. Will the recovery managers be the persons responsible for finding and matching the person to housing and housing vouchers? Are there special trainings for them to understand the work that has been done with the 811 waivers and other work on housing capacity? The Recovery Manager will be responsible for coordinating and monitoring services including housing services for the individual enrolled in HCBS-AMH. DSHS is working on accessing special trainings on housing for the Recovery Manager and will notify the Recovery Manager when these trainings become available. Also it is the expectation that the Recovery Manager will have knowledge of housing resources currently available in the areas the RM serves. 27. Can a service agency provide services from a home-based office? Home-based offices are allowed as long as they meet HCBS settings requirements. 28. What is the expected rollout date for these programs? The program is ready for implementation. We are currently waiting to execute contracts with providers so we can begin to refer and enroll individuals. 29. Will these programs have the same training requirements for providers as other DSHS programs? Please review our training requirements in our Provider Manual (Appendix A) on our webpage at http://www.dshs.state.tx.us/mhsa/hcbs-amh/. 30. When an individual is still enrolled in a facility and trying to transition to the community how should the Recovery Manager bill for services? Should the provider bill under Transition Services or Recovery Management Services? Recovery Management Transitional Fee. The Recovery Management Transitional Fee is aone- time fee that ispaid to the Recovery Manager for the firstthree months of the provision of Recovery Management transitional services. Theamount of thisone- time Recovery Management Transitional Fee is not dependent on the individuals length of stay during thesethree months of Recovery Management transitional services. The Recovery Management Transitional fee is 1842.87. Recovery Management Transitional Day rate After a period ofthree months Recovery Management transitional services will bepaid at a day rate. The Recovery Manager is not eligible to bill for Recovery Management transitional services provided after the individuals stay exceeds 180 days. The day rate is $19.28. 31. How often is IRP approved? It is anticipated that the RM and the individual will update the individuals IRP every 90 days to ensure IRP is reflection of the individuals current needs and desires. 32. If the Provider has a current contract with DSHS is this opportunity a conflict? No this is not a conflict. 33. What is the Recovery manager to individual ratio? Caseload sizes for the individual RM shall preferably be 10 individuals or less and shall be no more than 15 individuals. 34. State hospitals can refer to the HCBS program? What is the process if the referring LMHA to the State hospital is not a provider of HCBS? State Hospitals will be responsible for referring any individual that is residing in that state hospital who meets the initial criteria. This referral is submitted to the HCBS-AMH program. The LMHA that is linked with that State Hospital does not need to be a provider of services in order for the referral process to take place. If the individual is enrolled they will have a choice of which provider (of those available in their chosen community) they want to have provide HCBS-AMH services. 35. Can interns provide Community Psychiatric Supports and Treatment? Licensure candidates may provide service
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