471 NAC 32-006. MENTAL HEALTH AND SUBSTANCE USE DISORDER DAY TREATMENT SERVICES

006. MENTAL HEALTH AND SUBSTANCE USE DISORDER DAY TREATMENT SERVICES. Day treatment services are available to beneficiaries age 20 or younger when the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, the treatment is clinically necessary, and the need for this level of care is identified as part of an initial diagnostic interview, a substance use disorder assessment, or a substance use disorder addendum. These services are part of a continuum of care designed to prevent hospitalization or to facilitate the movement of the beneficiary in an acute psychiatric setting to a status in which the beneficiary is capable of functioning within the community with less frequent contact with the mental health or substance use disorder provider. Day treatment services must be community based, family centered, culturally competent, and developmentally appropriate. Day treatment services must meet all requirements in this chapter. 006.01 FAMILY COMPONENT. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. 006.02 COVERED DAY TREATMENT SERVICES. Day treatment programs must provide the following mandatory services and at least two of the following optional services. Payment for both mandatory services and optional services is included in the rate for day treatment. Individual services to the beneficiary by a supervising practitioner that are not administrative in nature and are clinically necessary will be considered for payment when billed by the supervising practitioner. Providers must not make any additional charges to Nebraska Medicaid or to the beneficiary. 006.02(A) MANDATORY SERVICES. The following services must be included in a program for day treatment to be approved for participation in Nebraska Medicaid (i) MEDICALLY NECESSARY PSYCHOTHERAPY AND SUBSTANCE USE DISORDER. These services must demonstrate active treatment of a patient with a serious emotional disturbance. These services are subject to program limitations. (1)Individual psychotherapy or substance use disorder counseling; (2)Group psychotherapy or substance use disorder counseling; (3)Family psychotherapy or substance use disorder counseling; and (4)Family assessment. (ii) MEDICALLY NECESSARY NURSING SERVICES. Medical services provided by a qualified registered nurse (RN) who evaluates the particular medical nursing needs of each beneficiary and provides for the medical care and treatment that is indicated on a Nebraska Medicaid approved treatment planning document and approved by the supervising practitioner. (iii) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary. Testing and evaluation services may be performed by a licensed psychologist, specially licensed psychologist or a psychology resident acting within their scope of practice. Clinical necessity must be documented by the program supervising practitioner. Reimbursement for psychological diagnostic services is included in the per diem. (iv) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility or provider. All medications must be stored in a special locked storage space and administered only by a physician, advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN). (v) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a day treatment program, services must be supervised by a registered dietitian, based on the beneficiary's individualized diet needs. Day treatment programs may contract for these services through an outside facility or provider. (vi)TRANSITION AND DISCHARGE. Transition and discharge planning that meets the requirements of this chapter. 006.02(B) OPTIONAL SERVICES. The program must provide two of the following optional services. The beneficiary must have a need for the services, the supervising practitioner must order the services, and the services must be a part of the beneficiary's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy. In appropriate circumstances, occupational therapy (OT) may be covered if prescribed as an activities therapy in a day treatment program: (i)Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a licensed or certified professional as listed below: (1)Recreational therapy; (2)Speech therapy; (3)Occupational therapy (OT); (4)Vocational skills therapy; and (5)Self-care services ; (ii) Therapeutic psychoeducational services may be provided as part of a total program. Therapeutic psychoeducational services must be provided by teachers specially trained to work with child and adolescents experiencing mental health or substance use disorder problems. These services may meet some strictly educational requirements, but must also include the therapeutic component. Professionals providing these services must be appropriately licensed and certified for the scope of practice; (iii)Social work services by a bachelor's level social worker: Social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment; (iv)Crisis intervention ; (v)Social skills building; (vi)Life survival skills; and (vii)Substance use disorder prevention, intervention, or treatment by a licensed alcohol and drug counselor (LADC) or provisionally licensed alcohol and drug counselor (LADC). 006.02(C) EDUCATIONAL PROGRAM SERVICES. Educational services, when required by law, must be available, though not necessarily provided by the day treatment program. Educational services must be only one aspect of the treatment plan, not the primary reason for admission or treatment. Educational services are not eligible for payment by Nebraska Medicaid, and do not apply towards the three hours or six hours of therapeutic services. 006.02(D) SPECIAL TREATMENT PROCEDURES IN DAY TREATMENT. If a child or adolescent needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in day treatment are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Parents or legal guardian or a Nebraska Medicaid case manager must approve use of these procedures through informed consent and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures: (i) De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures; (ii) Special treatment procedures may be used only when a child or adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; (iii) The child or adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO), or physical restraints; and (iv) Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner. 006.03 STANDARDS FOR PARTICIPATION. 006.03(A) PROVIDER STANDARDS. Providers of day treatment services must meet the following standards: (i) A community mental health or substance use disorder program providing day treatment must meet the following standards: (1)A community-based treatment facility appropriately licensed as determined by the Department of Health and Human Services, Division of Public Health; and (2)Accreditation by the Joint Commission , the Commission on the Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA) or the American Osteopathic Association (AOA). Agencies that have applied for accreditation may be enrolled on a provisional status; (ii) A psychiatric or substance use disorder hospital providing day treatment must: (1)Be maintained for the care and treatment of patients with primary psychiatric or substance use disorder disorders; (2)Be licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health; (3)Be accredited by the Joint Commission or the American Osteopathic Association (AOA); (4)Have licensed and certified psychiatric or substance use disorder beds; (5)Meet the requirements for participation in Medicare; and (6)Have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; (iii)A licensed and certified hospital which provides acute care services and which: (1)Is maintained for the care and treatment of patients with acute medical disorders; (2)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health; (3)Is accredited by the Joint Commission or the American Osteopathic Association (AOA); (4)Meets the requirements for participation in Medicare for acute medical hospitals; (5)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; and (6)Has adequate staff to meet the requirements of the mental health or substance use disorder day treatment standards; and (iv)If day treatment services will be provided in a school, the school must have a written contract with a mental health or substance use disorder program that meets these standards community mental health program or licensed hospital. This contract must demonstrate the working relationship between the school and the community mental health or substance use disorder program to provide the day treatment service. 006.03(B) SERVICE STANDARDS. (i)The program must provide a minimum of three hours of services five days a week, which is considered a half day for billing purposes. Six hours a day of services is considered a full day of services. Services may not be prorated for under three hours of service for a half day or six hours of services for a full day, but may be for up to 12 hours of service; (ii)A designated supervising practitioner must be responsible for the care provided in a day treatment program. The supervising practitioner must be present on a regularly-scheduled basis and must assume responsibility for all beneficiaries. If the supervising practitioner is present on a part-time basis, one of the clinical staff professionals acting within the scope of practice standards of the Nebraska Department of Health and Human Services, Division of Public Health must assume delegated professional responsibility for the program and must be present at all times when the program is providing services. Psychotherapy and substance use disorder counseling services must be provided by clinical staff who are operating within their scope of practice and under the direction of the supervising practitioner. The supervising practitioner's personal involvement must be documented in the beneficiary's clinical record; (iii)A licensed psychologist, physician, doctor of osteopathy, physician assistant (PA), or advanced practice registered nurse (APRN) may refer a beneficiary to a day treatment program, but all treatment must be prescribed and directed by the program supervising practitioner; (iv)All treatment must be conducted under the direction of the supervising practitioner in charge of the program; (v) The following criteria must be met for a beneficiary's admission to a day treatment program: (1)The beneficiary must have sufficient need for active treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and (2)Of all reasonable options for active treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's condition; (vi)Before the beneficiary is admitted to the program, a supervising practitioner must complete an initial diagnostic interview to validate the appropriateness of care; (vii) The program supervising practitioner must determine the diagnosis and prescribe the treatment, including the modalities and the professional staff to be used. They must be responsible and accountable for all evaluations and treatment provided to the beneficiary. The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary's response to the treatment interventions based on the recommendations, goals, and objectives: (1)The multi-disciplinary team must complete the treatment plan within the first 14 days after the beneficiary's admission to the program. The plan must be reviewed and revised by the multi-disciplinary team, including the supervising practitioner, at least every 30 days or more often if necessary; and (2)Changes in the treatment plan must be noted on the treatment planning document. An updated treatment plan must be completed every 30 days, or more frequently if necessary, to reflect changes in treatment needs. The treatment plan must be signed by the supervising practitioner for day treatment services. The treatment plan review must be documented on the treatment plan, if required, and in the medical records; (viii)The supervising practitioner must meet personally with the beneficiary for evaluation every 30 days, or more often, as clinically necessary. Reimbursement for the 30-day update visit is not included in the day treatment per diem and can be reimbursed separately; (ix)Every 30 days a utilization review must be conducted in accordance with this chapter. This review must be documented on the treatment plan, and the facility's treatment plan review form. Utilization review is not required for the calendar month in which the beneficiary was admitted; (x)The program must have a description of each of the services and treatment modalities available. This includes psychotherapy services, substance use disorder counseling, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other day treatment services: (1)The program must have a description of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family services; (2)The program must have a description of how the community-based requirement in this chapter will be met; (3)The program must state the qualifications, education, and experience of each staff member and the therapy services each provides; and (4)The program must have a daily schedule covering the total number of hours the program operates per day. The schedule must be submitted to Nebraska Medicaid for approval. The program must be fully staffed and supervised during the time the program is available for services, and must provide at least three hours of approved treatment for each day services are provided. This schedule must be updated annually, or more frequently if appropriate; (xi) When appropriate for brief crisis stabilization, outpatient observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used in accordance with the definition of outpatient in this chapter; and (xii)The program must have a written plan for immediate admission or readmission for appropriate inpatient services, if necessary. The written plan must include a cooperative agreement with a psychiatric or substance use disorder hospital or distinct part of a hospital, as outlined in this chapter. A copy of this agreement must accompany the provider application and agreement. 006.04 PROVIDER AGREEMENT. A provider of day treatment services must complete a provider agreement and submit the form to Nebraska Medicaid for approval. The provider must attach to the provider agreement a written overview of the program including philosophy, objectives, policies and procedures, and documentation of the requirements in this chapter are met. Staff must meet the standards outlined in this chapter, and (A)Community mental health or substance use disorder programs and licensed health clinics must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the completed form to Nebraska Medicaid for approval. A Nebraska Medicaid approved cost reporting document must also be submitted. Satellites of community programs must bill Nebraska Medicaid through their main community program, unless the satellite has a separate provider number under Medicare. A satellite of a community program that has a separate provider number under Medicare must complete a separate provider agreement. All claims submitted to Nebraska Medicaid by these satellites must be filed under the satellite's Nebraska Medicaid provider number. The facility must have in effect a utilization review plan applicable to all Nebraska Medicaid clients; and (B)Hospitals must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval. A Nebraska Medicaid approved cost reporting document must also be submitted. 006.04(i) ANNUAL RENEWAL. The program must renew the provider agreement, program overview, and cost report annually and whenever requested by Nebraska Medicaid . 006.05 COVERAGE CRITERIA FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER DAY TREATMENT. Nebraska Medicaid covers day treatment services for beneficiaries age 20 and younger when the services meet the requirements in in this chapter and the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen. Day treatment services must be prior authorized by Nebraska Medicaid or its designee. The beneficiary must be observed and interviewed by the supervising practitioner at least once every 30 days, or more frequently if medically necessary, and the interaction must be documented in the beneficiary's clinical record. 006.05(A) SERVICES NOT COVERED UNDER NEBRASKA MEDICAID. Payment is not available for day treatment services for beneficiaries: (i)Receiving services in an out-of-state facility, except as outlined in this title ; (ii)In long term care facilities; (iii)Whose needs are social or educational and may be met through a less structured program; (iv)Whose primary diagnosis and functional impairment is acutely psychiatric in nature and whose condition is not stable enough to allow them to participate in and benefit from the program; or (v)Whose behavior may be very disruptive or harmful to other program participants or staff members. 006.06 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification . In addition to the requirements of this chapter, each beneficiary's medical record must contain the following documentation: (A)The supervising practitioner's orders; (B)The treatment plan; (C)The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least daily. The progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan, as indicated by the beneficiary's condition, and discharge planning; (D)Documentation indicating compliance with all requirements in this chapter; (E)Records of the treatment plan review by the multi-disciplinary team including attendees and decisions; (F)The program's utilization review committee's abstract or summary; and (G)The discharge summary. 006.07 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning. 006.08 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following requirements. A site visit by Nebraska Medicaid for purposes of utilization review may be required for further clarification. 006.08(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide: (i)Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment; (ii)Utilization of professional services provided; (iii)High quality patient care; and (iv)Effective and efficient utilization of available health facilities and services. 006.08(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include: (i)The organization and composition of the utilization review committee which is responsible for the utilization review function; (ii)The frequency of meetings, which must occur at least every 30 days ; (iii)The type of records to be kept; and (iv)The arrangement for committee reports and their dissemination, including how the program and supervising practitioner is informed of the findings. 006.08(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must contain a licensed provider who is able to diagnose and treat major mental illness within their scope of practice and at least two clinical staff professionals, as defined in this chapter. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the beneficiary whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved. 006.08(D) BASIS OF REVIEW. The review must be based on: (i)The identification of the individual beneficiary by appropriate means to ensure confidentiality; (ii)The identification of the supervising practitioner; (iii)The date of admission; (iv)The diagnosis and symptoms; (v)The supervising practitioner's plan of treatment; and (vi)Other supporting materials the group may deem appropriate. 006.08(E) CONTENTS OF REPORT. The written report must contain : (i)An evaluation of treatment, progress, and prognosis based on: (1)Appropriateness of the current level of care and treatment; (2)Alternate levels of care and treatment available; and (3)The effective and efficient utilization of services provided; (ii)Verification that : (1)Treatment provided is documented in the beneficiary's record; (2)All entries in the beneficiary's record are signed by the person responsible for entry and dated. The supervising practitioner must sign and date all of their orders; and (3)All entries in the beneficiary's record are dated; (iii)Recommendations for : (1)Continued treatment; (2)Alternate treatment or level of care, or both; and (3)Disapproval of continued treatment; (iv)The date of the review; (v) The names of the program utilization review committee members; (vi)The date of the next review if continued treatment is recommended; and (vii) A copy of the admission review and the extended stay review must be attached to all claims for mental health services submitted to Nebraska Medicaid for payment. 006.09 LIMITATIONS ON REIMBURSEMENT OF ALLOWABLE COSTS. The following limitations apply to reimbursement of allowable costs: (A)Payment for a full day of day treatment is allowable when services are provided to a beneficiary for at least six hours per day; (B)Payment for a half day of day treatment is allowable when services are provided to a beneficiary for at least three hours per day but less than six hours per day. The rate for a half day of day treatment is limited to one half of the full day rate; and (C)For programs that provide services for more than six hours, and up to twelve hours, payment can be prorated by the hour. For each additional hour of service beyond six, Nebraska Medicaid will pay an additional amount based on the cost-report. 006.09(i) DOCUMENTATION FOR CLAIMS. The following documentation is required for all claims for day treatment and claims and must be kept in the beneficiary’s record: (1)A psychiatric assessment with mental status exam and diagnosis; (2)The treatment plan for admission and every 30 days thereafter; (3)Orders by the supervising practitioner; (4)A complete family assessment; (5)Nurses' notes; (6)Progress notes for all disciplines; and (7)All claims are subject to utilization review by Nebraska Medicaid prior to payment. 006.09(ii) EXCEPTION. Additional documentation from the beneficiary’s medical record may be requested by Nebraska Medicaid prior to considering authorization of payment. 006.09(iii) COSTS NOT INCLUDED IN THE DAY TREATMENT FEE. The mandatory and optional services are considered to be part of the fee for day treatment services. The following charges can be reimbursed separately from the day treatment fee when the services are necessary, part of the beneficiary's overall treatment plan, and in compliance with Nebraska Medicaid policy: (1)Direct beneficiary services performed by the supervising practitioner; (2)Prescription medications, including injectable medications; (3)Direct beneficiary services performed by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) other than the supervising practitioner; (4)Treatment services for a physical injury or illness provided by other professionals; and (5) If the beneficiary is enrolled with another Nebraska Health Connection vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity. 006.10 PROCEDURE CODES AND DESCRIPTIONS FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER DAY TREATMENT. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT); procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule . . .