471 NAC 20-025. OUTPATIENT PSYCHIATRIC SERVICES

025. OUTPATIENT PSYCHIATRIC SERVICES. All requirements in this chapter apply to outpatient psychiatric services. 025.01 COVERED OUTPATIENT PSYCHIATRIC THERAPEUTIC SERVICES. Nebraska Medicaid covers the following outpatient psychiatric therapeutic services for beneficiaries age 21 and older as defined in this chapter: (A)Psychiatric evaluation; (B)Psychological evaluation; (C)Psychological testing; (D)Individual psychotherapy; (E)Group psychotherapy overview must be approved by Nebraska Medicaid prior to billing for this service; (F)Family psychotherapy services; (G)Family assessment; (H)Medication checks by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) ; (I)Electroconvulsive therapy; (J) Annual supervision of eligible beneficiaries by a psychologist or a licensed independent mental health practitioner (LIMHP); (K) Functional family therapy (FFT); and (L) Opioid treatment program (OTP). 025.02 RESTRICTIONS. Nebraska Medicaid does not reimburse for services for diagnoses of developmental disabilities, or V codes as part of this chapter. 025.03 SKILLED NURSING. Skilled nursing services for the monitoring of medications is available through home health agencies . 025.04. PSYCHIATRIC THERAPEUTIC STAFF STANDARDS. The following psychiatric therapeutic staff may provide services and must meet the requirements as defined in this chapter: (A)Physician; (B)Licensed psychologist; (C) Physician assistant (PA); (D) Advanced practice registered nurse (APRN); (E)Licensed independent mental health practitioner (LIMHP); and (F)Allied health therapists. 025.04(i) LOCATION OF SERVICES. Outpatient psychiatric services by qualified staff may be provided in: (1)A licensed community mental health program which meets the criteria for approval by the Joint Commission , the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA), or the American Osteopathic Association (AOA) ; (2)A licensed and certified hospital which provides psychiatric services and which: (a)Is maintained for the care and treatment of patients with primary psychiatric disorders; (b)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state; (c)Is accredited by the Joint Commission or the American Osteopathic Association (AOA); (d)Has licensed and certified psychiatric beds; (e)Meets the requirements for participation in Medicare for psychiatric hospitals; and (f)Has in effect a utilization review plan applicable to all Nebraska Medicaid clients; (3)A licensed and certified hospital which provides acute medical services and which:- (a)Is maintained for the care and treatment of patients with acute medical disorders; (b)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state; (c)Is accredited by the Joint Commission or the American Osteopathic Association (AOA); (d)Meets the requirements for participation in Medicare for acute medical hospitals; and (e)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; (4)A physician's private office; (5)A licensed psychologist's private office; (6)An allied health therapist's private office; (7)The beneficiary's home; (8)Nursing homes; or (9)Rural mental health clinics or federally qualified health centers. 025.05 PROVIDER AGREEMENT. A provider of psychiatric outpatient services must complete a provider agreement, and submit the form to Nebraska Medicaid for approval. 025.05(A) INDEPENDENT PSYCHIATRIC SERVICE PROVIDERS. Independent psychiatric service providers must complete the appropriate form . The provider agreement issued to the supervising practitioner or clinic is used to claim services provided by allied health therapists who are in the practitioner’s or clinic’s employ or supervision. For outpatient psychiatric services provided through a group practice, the provider agreement must be kept current by providing Nebraska Medicaid with: (i)The termination date of any therapist leaving the group practice; (ii)The initial employment date of any therapist joining the group practice; and (iii)A current resume detailing education and clinical experience for each application for allied health therapists. 025.05(B) HOSPITALS. Hospitals as defined in this chapter providing outpatient psychiatric services must complete the appropriate Nebraska Medicaid approved provider agreement orm . 025.05(C) VERIFICATION. Providers are responsible for verifying that allied health therapists, physicians, physician assistants (PA), advanced practice registered nurses (APRN), and licensed psychologists are appropriately licensed for the correct scope of practice. 025.05(D) GEOGRAPHICALLY DEPRIVED AREAS. A physician who is qualified, skilled, and experienced in the diagnosis and treatment of psychiatric disorders may serve as an alternative to a psychiatrist for outpatient services in a geographically-deprived area. A resume detailing the physician's mental health education and experience must accompany the provider agreement. When outpatient psychiatric services are provided under these conditions, the physician is subject to all policy requirements outlined for psychiatrists. Psychiatric services provided by the attending physician, other than a psychiatrist, are limited to psychotherapy services provided in a physician's office which do not exceed six months without documented consultation between the physician providing the service and a psychiatrist. 025.06 COVERAGE CRITERIA FOR OUTPATIENT PSYCHIATRIC SERVICES. Nebraska Medicaid covers outpatient psychiatric therapeutic services listed in this chapter when the services are medically necessary and provide active treatment as defined in this chapter. 025.06(A) DOCUMENTATION OF MEDICAL NECESSITY AND ACTIVE TREATMENT. Medical necessity and active treatment for outpatient services is documented through the use of Nebraska Medicaid’s approved treatment planning document, in accordance with this chapter which must be developed by a licensed practitioner and supervising practitioner based on a thorough evaluation of the beneficiary's restorative needs and potentialities for a primary psychiatric diagnosis. 025.06(B) SERVICES PROVIDED BY ALLIED HEALTH THERAPISTS. Services provided by allied health therapists, as defined in this chapter must be prescribed and provided under the direction of a supervising practitioner. Supervision must meet the active treatment criteria in this chapter . 025.06(B)(i) RE-EVALUATION. The supervising practitioner must personally re-evaluate the beneficiary through a face-to-face contact annually or more often, if necessary. psychiatric service provider accepts the client; and 025.07 DOCUMENTATION IN BENEFICIARY’S CLINICAL RECORDS. : All documents submitted to Nebraska Medicaid must contain sufficient information for identification . . The beneficiary's medical record must also include: (A)The initial diagnostic interview; (B)The treatment plan, including the initial document, updates, and current treatment plan; (C)The beneficiary's diagnosis. A provisional or interim psychiatric diagnosis must be established by the supervising practitioner at the time the beneficiary is accepted for treatment. This diagnosis must be reviewed and revised as a part of the treatment plan; (D)A chronological record of all psychiatric services provided to the beneficiary, the date performed, the duration of the session, and the staff member who conducted the session; (E)A chronological account of all medications prescribed, the name, dosage, and frequency to be administered and beneficiary's response; (F)6A comprehensive family assessment; (G)A clear record of family and community involvement; (H)Documentation verifying coordination with other therapists when more than one provider is involved with the beneficiary and family; and (I)Transition and discharge planning. 025.08 UTILIZATION REVIEW. Payment for outpatient psychiatric services is based on adequate legible documentation of medical necessity and active treatment. All outpatient claims are subject to utilization review before payment. 025.08(A) ADDITIONAL DOCUMENTATION. Additional documentation from the beneficiary's clinical record may be requested prior to considering authorization of payment when the treatment plan does not adequately document medical necessity or active treatment. 025.09 PSYCHOLOGICAL TESTING AND EVALUATION SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary. 025.09(A) PROVIDER. Testing and evaluation services may be performed by a licensed psychologist, or by a specially licensed psychologist or a master's level person approved to administer psychological testing under the supervision of a licensed psychologist. 025.09(A)(i) SUPERVISING PRACTITIONER. If testing and evaluation services are provided by a licensed, non-certified psychologist, the services must be ordered by a supervising practitioner. 025.09(A)(ii) COPY OF TESTING NARRATIVE SUMMARY. A copy of the testing narrative summary must be kept in the beneficiary’s clinical record. If the evaluation is court ordered, the provider must note this on the treatment plan and include documentation of medical need for the service. 025.09(B) GRAND-PARENTED MASTERS PSYCHOLOGISTS. Services provided by master's level clinical psychologists whose certification has been grand-parented by the Department of Health and Human Services, Division of Public Health may be covered under this chapter. Documentation of the grand-parented status may be required. 025.09(C) MEDICATION CHECKS. Medication checks may only be done when medically necessary. When a physician, physician assistant (PA) or advanced practice registered nurse (APRN) provides psychotherapy services, medication checks are considered a part of the psychotherapy service. 025.09(C)(i) MEDICATION CHECK. The supervising physician may provide a medication check when a licensed psychologist or an allied health therapist provides the psychotherapy service. Only physicians and psychiatrically trained physician assistants (PA) or advanced practice registered nurses (APRN) may provide medication checks. 025.09(D) TRAVEL TO THE HOME OF BENEFICIARIES WHO HAVE HAVE HANDICAPS. If a beneficiary has a handicapping physical condition that prevents them from traveling to a mental health clinic or office, the provider may request prior authorization to bill for mileage to the beneficiary's home. The information requested must be provided, in writing, to Nebraska Medicaid or their designee for consideration. The following requirements must be met: (i)The provider requests prior authorization before the initiation of services; (ii)The treatment must meet the criteria for active treatment and medical necessity; (iii)The beneficiary's handicapping physical condition prevents their travel to the mental health clinic or office; and (iv)The beneficiary's home is more than 30 miles from the clinic or office. 025.09(E) FAMILY ASSESSMENT. Nebraska Medicaid covers family assessments used to identify the functional level of the family unit and the system changes that would influence this functional level. This includes interviews with the beneficiary and collateral parties. 025.09(F) ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE BENEFICIARIES BY A PSYCHOLOGIST OR A LICENSED INDEPENDENT MENTAL HEALTH PRACTITIONER (LIMHP). The supervising practitioner must be available in person or by telephone to provide assistance as needed during the time services are being provided. The critical involvement of the supervising practitioner is to be reflected in the initial diagnostic interview, the treatment plan, and the interventions provided. 025.09(G) FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) is family therapy targeted at youth. 025.09(G)(i) INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview must be completed prior to the beginning of treatment and will serve as the initial treatment plan until a comprehensive treatment plan is completed. 025.09(G)(ii) STAFFING. All staffing must be adequate to meet the individualized treatment needs of the beneficiary and meet the responsibilities of each staff position as outlined in the functional family therapy (FFT) model. 025.09(G)(iii) TREATMENT PLAN REQUIREMENTS. Assessments and treatment must address mental health and substance use disorder needs, and mental health and emotional issues related to medical conditions. The treatment plan must be individualized and include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional. The treatment plan must be developed with the beneficiary and the identified, appropriate family members as part of the outpatient family therapy treatment planning process. The treatment plan must meet the following requirements: (1) The treating provider must consult with or refer to other providers for general medical, psychiatric, and psychological needs as indicated; (2) It is the treating provider’s responsibility to coordinate with other treating professionals as needed; (3) The treatment plan will be reviewed every 90 days or more often if clinically indicated; (4) After hours crisis assistance must be available; and (5) Services must be trauma informed, culturally sensitive, age and developmentally appropriate, and incorporate evidence-based practices when appropriate. 025.09(G)(iv) FUNCTIONAL FAMILY THERAPY (FFT). A functional family therapy (FFT) treatment provider must have a master’s degree or greater and be a member of an active team. An active functional family therapy (FFT) team requires a functional family therapy (FFT) certified clinical supervisor and at least three functional family therapy (FFT) certified treatment providers working collaboratively with one another using the functional family therapy (FFT) model. 025.09(G)(v) TREATMENT PROVIDERS. Treatment providers may be any of the following: physician, physician assistant (PA), advanced practice registered nurse (APRN), nurse practitioner (NP), licensed psychologist, provisionally licensed psychologist, licensed independent mental health practitioner (LIMHP), licensed mental health professional, and a provisionally licensed mental health practitioner (LMHP) acting within their scope of practice. 025.09(G)(v)(1) TREATMENT CLINICAL SUPERVISORS. Treatment clinical supervisors must be physicians, physician assistants (PA), licensed psychologists, or licensed independent mental health practitioners (LIMHP) certified in functional family therapy (FFT) model and with experience in the practice of psychotherapy. All psychiatric and psychotherapy services will be prescribed and provided under the supervision and direction of a supervising practitioner. Supervision is not a billable service. 025.09(G)(v)(2) TREATMENT ASSESSMENT PROVIDERS. Treatment assessment providers may be any of the following: physicians, physician assistants (PA), psychiatric advanced practice registered nurse practitioners (APRN), psychologists, provisionally licensed psychologists, or licensed independent mental health practitioners (LIMHP), all acting within their scope of practice. 025.09(H) OPIOID TREATMENT PROGRAM (OTP). An opioid treatment program (OTP) treatment must be compliant with federal regulations. 025.09(H)(i) CERTIFICATION. Treatment must be provided by Substance Abuse and Mental Health Services Administration (SAMHSA) certified treatment centers that meet federal regulatory requirements. 025.09(H)(ii) COORDINATION. Opioid treatment must be coordinated through a collaborative process that implements, monitors, and evaluates the options and services required to meet the beneficiary’s needs and includes referrals to outside resources when the needed services are not offered by the opioid treatment program (OTP). Providers must establish a plan of care with a clinically appropriate maintenance period that is based on assessments of withdrawal symptoms using standardized scales and evidence-based practice. 025.09(H)(iii) ASSESSMENTS. Ongoing assessments must meet the following requirements: (1) A substance use assessment must be completed prior to initiation of services and must be updated annually; (2) A substance use addendum should be completed if determined to be medically necessary; and (3) Assessments and addendums must be completed by one of the following licensed medical professionals: (a) Licensed or provisionally licensed psychologist; (b) Licensed independent mental health practitioner (LIMHP); (c) Licensed or provisionally licensed mental health practitioner (LMHP); and (d) Licensed or provisionally licensed alcohol and drug counselor (LADC). 025.09(H)(iv) OPIOID AGONIST. Opioid agonist medications must be administered and dispensed by licensed professionals authorized by law. A physician, physician assistant (PA) or advance practice registered nurse (APRN) must determine and document, in writing, the initial dose of opioid agonist medications and schedule to be followed for each beneficiary. This information is to be communicated to the licensed medical staff supervising the dispensing of any opioid replacement treatment medication. Opioid agonist medications are provided in conjunction with rehabilitative and medical services. 025.10 PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES IN A HOSPITAL. Nebraska Medicaid pays for covered outpatient mental health services, except for laboratory services, at the lower of: (i)The provider's submitted charge; or (ii)The allowable amount for that procedure code in the Medicaid Practitioner Fee Schedule for that date of service. The allowable amount is indicated in the fee schedule as: (1)The unit value multiplied by the conversion factor; (2)The maximum allowable dollar amount; or (3)The reasonable charge for the procedure as determined by Nebraska Medicaid , indicated as BR - by report or RNE - rate not established in the fee schedule. 025.10(B) REVISIONS OF THE FEE SCHEDULE. Nebraska Medicaid reserves the right to adjust the fee schedule to: (i)Comply with changes in state or federal requirements; (ii)Comply with changes in national standard code sets ; (iii)Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and (iv)Adjust the allowable amount when Nebraska Medicaid determines that the current allowable amount is: (1)Not appropriate for the service provided; or (2)Based on errors in data or calculation. 025.10(C) UPDATES TO FEE SCHEDULE. Nebraska Medicaid may issue revisions of the Nebraska Medicaid Practitioner Fee Schedule during the year that it is effective. Providers will be notified of the revisions and their effective dates. 025.11 BILLING REQUIREMENTS. For outpatient psychiatric service providers, the following requirements must be met: (A)Community mental health programs providing outpatient psychiatric services must submit all claims for outpatient services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim; (i) Payment for approved outpatient psychiatric services provided by employees of a community mental health program is made to the facility; (B)Hospitals providing outpatient psychiatric services must submit all claims for non-physician services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim; (i) All physician services must be submitted on the appropriate Nebraska Medicaid approved health care claim form ; and (ii) Payment for approved outpatient psychiatric services provided by employees of a hospital is made to the facility; (C)Independent providers of outpatient psychiatric services must submit all claims for outpatient psychiatric services provided in their private office on the appropriate Nebraska Medicaid approved health care claim form or electronic claim; and (i) Payment for approved outpatient psychiatric services provided in an independent provider's private office is made to the provider as identified on the provider agreement. 025.12 DOCUMENTATION FOR CLAIMS. For outpatient psychiatric services, unless otherwise instructed by Nebraska Medicaid or their designee, the following documentation must be kept in the beneficiary’s file for each claim: (A)The initial treatment plan; or (B)An updated version of the treatment plan completed every 90 days. 025.13 PSYCHOLOGICAL TESTING AND EVALUATION. For psychological testing and evaluation services, unless otherwise instructed by Nebraska Medicaid, the following information must be kept in the beneficiary’s file: (A)The treatment plan; (B)Medical necessity for the service documented on the treatment plan; (C)The documentation that the evaluation services will reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary; and (D)A narrative of the testing results. 025.14 PROCEDURE CODES AND DESCRIPTIONS. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule .