Transcription
Home and CommunityBased ServicesAdult Mental HealthBilling GuidelinesHealth and Human ServicesCommissionJanuary 2022
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTable of ContentsTable of Contents . 21000 HCBS-AMH Billing Guidelines Definitions . 52000 Introduction . 162100 HCBS-AMH Services and Codes .162110 HCBS-AMH Service Utilization .182200 General Billing Requirements .212210 Verification of Medicaid Eligibility .222300 Service Rates .222310 Rates Schedule .222320 Services with Requisition Fee .222330 Cost Reporting .222400 Service Authorization .232500 Provider Qualifications .232600 Location of Service Provision .232610 Excluded Locations for Medicaid Services .232620 Home and Community Based Services Approved Settings .242630 Exceptions .262700 Billable Units of Service .262710 15 Minute Unit of Service .262720 Hourly Unit of Service .312730 Daily Unit of Service .322740 Other Units of Service (Event, Encounter, Mile, Meal) .322800 Documentation of Service Provision .322810 General Documentation Requirements to Support Service Provision .332820 Written Service Log .332830 Written Summary Log .342840 Proof of Residence.352900 Multiple Services .353000 Service Specific Billing Requirements . 383100 Medicaid Billable Activities and Services .383110 Adaptive Aids .383120 Supported Home Living .443130 Assisted Living .483140 Supervised Living .513150 Host Home/Companion Care .543160 Community Psychiatric Supports and Treatment .573170 Employment Services.592
Home and Community-Based Services-Adult Mental HealthBilling Guidelines3180 Home Delivered Meals.663190 Minor Home Modifications .6731100 Nursing.7031110 Peer Support .7431120 HCBS-AMH Recovery Management .7531130 HCBS Psychosocial Rehabilitation Services.7831140 Respite Care .8031150 Substance Use Disorder Services .8231160 Transition Assistance Services .8531170 Transportation .863200 General Revenue Reimbursable Activities and Services.883210 HCBS-AMH Services Provided to Indigent Persons .883300 Non-Medicaid HCBS-AMH Services .883310 Flexible Funds.883320 HCBS-AMH Pre-Engagement Services .893330 Non-Medicaid Development of IRP .903340 HCBS-AMH Medicaid Services Provided in the Hospital .913350 HCBS-AMH Recovery Management Conversion Services .923400 Non-Reimbursable/Non-Billable Activities .934000 Invoicing and Payment . 944100 General Invoicing Information .944110 Submitting an Invoice .944120 Time Periods for Service .954130 Service Claim Requirements .954200 HHSC Review of Invoice.954210 General Invoice Review .954300 Payment.965000 Medicaid Billing . 985100 Submitting Medicaid Claims.985110 Texas Medicaid & Healthcare Partnership .985200 Medicaid Effective Date.985300 Non-HCBS State Plan Services .986000 Exclusions . 996100 Room and Board.996200 Payor of Last Resort .996210 Medicaid Payor of Last Resort.996220 General Revenue Payor of Last Resort .996230 Co-Payment of Person.997000 Forms . 1027100 HCBS-AMH Invoice Template . 1023
Home and Community-Based Services-Adult Mental HealthBilling Guidelines7200 Transportation Log. 1027300 Documentation of Transportation as Part of HCBS-AMH Service . 1024
Home and Community-Based Services-Adult Mental HealthBilling Guidelines1000 HCBS-AMH Billing Guidelines DefinitionsTermDefinitionDefinitionActivities of Daily Living (ADLs)Routine daily activities. These activitiesinclude performing personal hygieneactivities, dressing, meal planning andpreparation, managing finances, shoppingfor food, clothing, and other essential items,performing essential household chores,communicating by phone or other media,navigating public transportation,participating in the community and otheractivities as defined by the department.AdministratorThe individual in charge of a HCBS-AMHProvider Agency or Recovery ManagementEntity.Billable ActivityAn activity for which a service claim may besubmitted for services.Calendar dayMidnight through 11:59 p.m.Clinical Management for Behavioral HealthServices (CMBHS)An electronic health record created andmaintained by HHSC for the use ofcontracted Mental Health and SubstanceAbuse Services. Contracted HCBS-AMHProvider Agencies and RecoveryManagement Entities shall utilize CMBHS asdirected by HHSC.Community Mental Health Center (CMHC)An entity established in accordance with theTexas Health and Safety Code, §534.001, asa community mental health center or acommunity mental health and mentalretardation center.5
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionCredentialingA process to review and approve a staffmember's educational status, experience,licensure and certification status (asapplicable) to ensure that the staff membermeets the departmental requirements forservice provision. The process includesprimary source verification of credentials,establishing and applying specific criteriaand prerequisites to determine the staffmember's initial and ongoing competencyand assessing and validating the staffmember's qualification to deliver care. Recredentialing is the periodic process ofreevaluating the staff's competency andqualifications.Calendar MonthThe first day of a month through the last dayof that month.Calendar WeekSunday through Saturday.Calendar YearJanuary through December.Claims AdministratorContracted entity responsible for conductingcertain Medicaid administrative activities onbehalf of the single state Medicaid agency.Clean ClaimIn accordance with the Title 42, Code ofFederal Regulations (CFR), §447.45(b),defined as a service claim submitted by aprogram provider for a service delivered toan individual that can be processed withoutobtaining additional information from theprovider of the service or from a third party.Competitive EmploymentEmployment that pays an individual at orabove the greater of:(A) the applicable minimum wage; or(B) the prevailing wage paid to personswithout disabilities performing the sameor similar work.6
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionCo-PaymentA fixed fee an individual pays for a service atthe time the service is provided. CoPayments are determined in accordance withTitle 25, Texas Administrative Code (TAC),Chapter 412 Subchapter C (relating toCharges for Community Services).Court-Appointed GuardianA Guardian who is given the legal authorityby court order to care for the personal andproperty interests of another person, who isreferred to as a ward of the state. Aguardian who has been given responsibilityby the court for both the personal well-beingand financial interests of a person is knownas a general guardian.A person can have two separate courtappointed guardians. For example, the courtcan choose to appoint one person asguardian of the person and a differentperson as the guardian of the person’sestate.Guardian is a distinction from LegallyAuthorized Representatives, because theguardian is considered legally responsible forthe person.DeductiblePayment made by an individual in a specifiedamount for a service received beforecoverage begins for that service under theinsurance policy.Direct Service Provider AgencyAn employee or a contractor of a HCBS-AMHProvider Agency or Recovery ManagementEntity who provides HCBS-AMH Service(s)directly to a person.Disenrollment DateThe date of which a person exits theprogram.Comprehensive and preventive health careEarly and Periodic Screening, Diagnostic andservices for children under age 21 who areTreatment (EPSDT) benefitenrolled in MedicaidEnrollment DateDelineation of time in relation to the person’senrollment into the program.7
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionEncounter DataDetails related to the HCBS-AMH servicesrendered by provider to the person enrolledin HCBS-AMH.Extended ShiftDuring a 24-hour period, a combined periodof time of more than 16 hours.Face-to-faceWithin the physical presence of anotherperson who is not asleep.An appraisal of a person's current healthstatus that:(A) contributes to a comprehensiveFocused Assessmentassessment conducted by a registerednurse;(B) collects information regarding theperson's health status; and(C) determines the appropriate health careprofessionals or other persons who needthe information and when the informationshould be provided.HCBS-AMH ServicesHome and Community-based Servicesprovided under the HCBS-AMH Program.HCBS-AMH Pre-EngagementServices provided by the LMHA/LBHA toperform the referral and enrollment processfor persons seeking enrollment as an HCBSAMH participant (Participant) who reside inthe community of the LMHA/LBHA servicearea. Pre-engagement services includecompleting the HCBS-AMH UniformAssessment, obtaining and completingreferral documentation required todetermine program eligibility, completingenrollment forms, and working to obtainnecessary documents for determiningMedicaid eligibility.IndividualA person who is currently enrolled in theHCBS- AMH Program and receiving servicesor is involved in the enrollment process forHCBS- AMH.8
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionIndividual Recovery Plan (IRP)A written, individualized plan, developed inconsultation with the individual and LAR, ifapplicable; person's treatment team andproviders; and other persons according tothe needs and desire of the person, whichidentifies the necessary HCBS to be providedto the person. The IRP must be approved bythe department before a provider maydeliver HCBS-AMH services.The IRP also serves as the treatment plan orrecovery plan and is developed inaccordance with 26 TAC, Part 1, Chapter306, Subchapter D (relating to Mental HealthServices--Admission, Continuity, andDischarge) and 26 TAC, §301.353 (relatingto Provider Responsibilities for TreatmentPlanning and Service Authorization).The IRP must be approved by thedepartment before a provider may deliverHCBS-AMH.Integrated EmploymentEmployment at a work site at which a personroutinely interacts with people withoutdisabilities other than the person's work sitesupervisor or direct service providers.Interdisciplinary Team (IDT)A group of individual entities that helpdesign, manage, facilitate and implement anintegrated approach to a person’s system ofcare thatutilizes inclusion, policy and practice to bestserve the person’s behavioral and mentalhealth needs.InvoiceThe file that a HCBS-AMH Provider willsubmit to HHSC as evidence of HCBS-AMHservices provided. This file is generated byencounter data.Legally Authorized Representative (LAR)A LAR is an individual or judicial or otherbody authorized by law to act on behalf of aperson with regard to a particular matter.The term may include a parent, guardian, ormanaging conservator of a minor.9
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionLicensed Practitioner of the Healing Arts(LPHA)A person who is a physician, a licensedprofessional counselor, a licensed clinicalsocial worker, a licensed psychologist, anadvanced practice nurse, or a licensedmarriage and family therapist.Licensed Vocational Nurse (LVN)A person licensed to practice vocationalnursing in accordance with TexasOccupations Code, Chapter 301.Local Mental Health Authority / LocalBehavioral Health Authority (LMHA/LBHA)An entity designated as the local mentalhealth authority by the department inaccordance with the Texas Health and SafetyCode, §533.035(a). For purposes of thissubchapter, the term includes an entitydesignated as a local behavioral healthauthority.Non-HCBS-AMH ServicesServices provided by any funding sourceother than HCBS-AMH. Examples include butare not limited to other State Plan Services,Temporary Assistance for Needy Families(TANF), and Personal Care Services (PCS).PreauthorizationThe authorization a Recovery Manager willobtain, for billing purposes, prior to assistinga participant in dis-enrolling from anotherHCBS program and enrolling HCBS-AMH.Prior ApprovalAssurance from HHSC, prior to a programprovider purchasing a requested adaptive aidor minor home modification, that theprogram provider will be paid for theadaptive aid or minor home modification ifthe provider complies with HCBS-AMH BillingGuidelines.10
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionProvider AgencyAn agency, organization, or individual thatmeets credentialing standards defined byHHSC and enters into a Provider Agreementfor HCBS-AMH. The HCBS-AMH Providermust ensure provision of all HCBS-AMHservices directly and /or indirectly byestablishing and managing a network ofSubcontractors. The HCBS-AMH Provider hasthe ultimate responsibility to comply with theProvider Agreement and Manual regardlessof service provision arrangement (directly orthrough Subcontractors).ProviderAn HCBS-AMH Provider Agency or RecoveryManagement Entity who has entered into aProvider Agreement with HHSC for theprovision of HCBS-AMH.Provider AgreementA document which is required as a conditionof enrollment or participation as an HCBSAMH Provider. Also called a “contract,” awritten agreement referring to promises oragreements for which the law establishesenforceable duties and remedies between anHCBS-AMH Provider and HHSC.Quality ManagementA program developed and implemented bythe provider by which organizationalperformance and services are assessed andevaluated to ensure the existence of thosestructures and processes necessary for theachievement of individual outcomes andcontinuous quality improvement.11
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionA staff member who is credentialed as aQMHP- CS who has demonstrated anddocumented competency in the work to beperformed and:(A) Has a bachelor's degree from anQualified Mental Health Professional –Community Services (QMHP-CS)accredited college or university with aminimum number of hours that isequivalent to a major (as determined bythe LMHA or Managed Care Organization(MCO) in accordance with 26 TAC,§301.331 (relating to Competency andCredentialing)) in psychology, socialwork, medicine, nursing, rehabilitation,counseling, sociology, human growth anddevelopment, physician assistant,gerontology, special education,educational psychology, early childhoodeducation, or early childhoodintervention;) – A person authorized bylaw to act on behalf of a child oradolescent with regard to a matterdescribed in this subchapter, including,but not limited to, a parent, guardian, ormanaging conservator.(B) Is a registered nurse; or(C) Completes an alternative credentialingprocess identified by the HHSC.RecoveryA process of change through which personsimprove their health and wellness, live aself- directed life, and strive to reach theirfull potential.Recovery Manager (RM)Recovery management entity contractedwith HHSC to provide recovery managementservices.Recovery Management EntityAn entity that employs individual recoverymanagement providers.Recovery Management Transitional ServicesRecovery Management services provided toa person who is residing at a psychiatrichospital at the time of their enrollment inHCBS-AMH.12
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionRecovery Management Conversion ServicesWork conducted by the Recovery Managerwhen a participant is enrolled in anotherHCBS program and decides to discontinueservices in the program and enroll in HCBSAMH. The RM coordinates thedisenrollment/enrollment process for theparticipant.Work conducted by the Recovery Managerwhen a participant is in a nursing facility.The RM coordinates with staff and providersto prepare the participant for discharge.RM must receive preauthorization of servicesbefore providing conversion services.Referring EntityThe entity that initiates the referral processof the person to HCBS-AMH.Registered NurseA person licensed to practice professionalnursing in accordance with TexasOccupations Code, Chapter 301ResidenceA place of bona fide and continuoushabitation that is a structure with a commonroof and common walls, except if thestructure contains more than one dwellingsuch as an apartment complex or duplex,“residence" means a dwelling within thestructure. A person may have only oneresidence.RN Clinical SupervisionThe monitoring for changes in health needsof the person, overseeing the nursing careprovided and offering clinical guidance asindicated, to ensure that nursing care is safeand effective and provided in accordancewith the nursing service plan for the person.13
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionAn extensive evaluation of a person's healthstatus that:(A) addresses anticipated changes in the(B)(C)(D)RN Nursing Assessment(E)(F)(G)conditions of the person as well asemergent changes in the person's healthstatus;recognizes changes to previous conditionsof the person;synthesizes the biological, psychological,spiritual and social aspects of theperson's condition;collects information regarding theperson's health status;analyzes information collected about theperson's health status to make nursingdiagnoses and independent decisionsregarding nursing services provided tothe person;plans nursing interventions and evaluatesthe need for different interventions; anddetermines the need to communicate andconsult with other direct service providersor other persons who provide supports tothe person.Service ClaimA request submitted by a program providerto be paid by HHSC for a serviceState Plan ServicesServices that are offered under the MedicaidState Plan service array, which may beprovided by any credentialed Medicaid StatePlan direct service provider.Status DefinitionsThe language that describes the status ofthe person in relation to the enrollmentprocess. HCBS-AMH service definitions anddescriptions are located in the HCBS-AMHProvider Manual.14
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesTermDefinitionSubcontractorA single person, organization, or agency thatenters an agreement with a HCBS-AMHProvider Agency to provide one or moreHCBS-AMH services. A subcontractor mustmeet minimum qualifications defined byHHSC.SupervisionThe process of directing, guiding andinfluencing the outcome of an unlicensedstaff's performance.Suspended StatusEnrollment status of a person who is notdischarged from HCBS-AMH but whoseservices have been suspended, except asotherwise allowed by HHSC.Uniform AssessmentA standardized assessment identified byHHSC to determine HCBS-AMH programeligibility and clinical needs of the person.To be determined eligible to participate inthis program, each person must receive auniform assessment as defined by thedepartment, based on the needs andstrengths of the person. The uniformassessment will be the basis for the IRP. Theassessor must consult with the person; theperson's LAR, treatment team, providers;and other persons according to the needsand desire of the person to conduct theuniform assessment. The uniformassessment must be conducted face- toface; take into account the ability of theperson to perform two or more activities ofdaily living; and assess the person's need forHCBS-AMH.Volunteer WorkWork performed by an individual withoutcompensation that is for the benefit of anentity or person other than the individualand is performed in a location other than theindividual’s residence.15
Home and Community-Based Services-Adult Mental HealthBilling Guidelines2000 Introduction2100 HCBS-AMH Services and CodesHCBS-AMH ServiceAdaptive AidsProcedureModifier 1 Modifier 2CodeModifier 3UnitUnit RateT599HKHEN/APer encountercostAssisted Living ServicesT2031HKHEN/APer day 31.47Community Psychiatric Supports andTreatmentH0036HKHEN/APer hour 79.53Employment AssistanceH2025HKHEN/APer hour 26.07Supported EmploymentH2023HKHEN/APer hour 26.07Flexible FundsH2038HKHWN/APer encountercostPre-EngagementT2038HKHBN/APer 15minutes/max64 units 3.97HCBS-AMH Recovery ManagementH2015HKHEN/APer 15minutes 31.69Recovery Management ConversionServices FeeH2015HKU1N/APer encounter 614.29Recovery Management TransitionalDay RateH2015HKTUN/APer day 19.28Recovery Management Transitional feeH2015HKHWN/APer enrollment 1,842.8716
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesHCBS-AMH ServiceProcedureModifier 1 Modifier 2CodeModifier 3UnitUnit RatePer 15minutes 5.39HCBS Psychosocial RehabilitationServices GroupH2019HKHQUN(2),UP(3),UQ(4),UR(5),US(6)HCBS Psychosocial RehabilitationServices IndividualH2019HKHEN/APer 15minutes 26.93Home Delivered Meals MedicaidS5170HKHEN/APer meal 6.93Home Delivered Meals non-MedicaidS5170HKHWN/APer meal 5.61Host Home/ Companion CareS5136HKHEN/APer day 82.40Minor Home ModificationsS5165HKHEN/APer encountercostNursing Licensed Vocational Nurse (LVN)S9124HKHEN/APer hour 29.69Nursing registered Nurse (RN)S9123HKHEN/APer hour 43.39Peer SupportH0038HKHEN/APer 15minutes 6.25Respite Care In-HomeT1005HKHEN/APer 15minutes 2.49Respite Care out-of-home 24-hourResidential Habilitation HomeT2033HKHEN/APer day 147.12Respite Care out-of-home Adult FosterCare homeS5140HKHEN/APer day 33.28Respite Care out-of-home LicensedAssisted Living FacilityS5151HKHEN/APer day 52.55Respite Care out-of-home Nursing FacilityH0045HKHEN/APer day 82.5617
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesHCBS-AMH ServiceProcedureModifier 1 Modifier 2CodeSubstance Use Disorder ServicesAssessmentH0001HKModifier 3HHN/AUnitUnit RatePerassessment 41.35Per hour 16.00Substance Use Disorder Services ce Use Disorder ServicesIndividualH0004HKHEN/APer 15minutes 11.75Supervised Living ServicesH2013HKHEN/APer day 147.12Supported Home LivingS5130HKHEN/APer 15minututes 5.60Transition Assistance ServicesT2038HKHEN/APer eventcostTransition Assistance ServicesRequisition feeT2038HKCGN/APer event 158.28TransportationA0080HKHEN/APer mile .552110 HCBS-AMH Service UtilizationHCBS-AMH ServiceStandard Anticipated UnitsHigh Need UtilizationAdaptive Aids 500 1,000Assisted Living ServicesDailyN/A4 to 5 units/month6 to 8 units/monthEmployment Services Employment Assistance8 to 13 units/month14 to 17 units/monthEmployment Services Supported Employment10 to 21 units/month22 to 38 units/monthAs AuthorizedAs AuthorizedCommunity Psychiatric Supports and TreatmentFlexible Funds18
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesHCBS-AMH ServiceStandard Anticipated UnitsHigh Need Utilization1 to 32 unit/per participant33 to 64 unit/per participant24 to 48 units/week or max of 192units/month49 to 64 units/week or max of256 units/monthHCBS Psychosocial Rehabilitation Services Group20 to 40 units/month41 to 65 units/monthHCBS Psychosocial Rehabilitation Services Individual20 to 40 units/month41 to 65 units/monthHome Delivered Meals Medicaid20 to 45 units/month46 to 62 units/monthHome Delivered Meals Non-Medicaid20 to 45 units/month46 to 62 units/monthHost Home/Companion CareDailyN/AMinor Home Modifications 500 1,000Nursing Licensed Vocational Nurse (LVN)12 to 24 units/month25 to 56 units/monthNursing Registered Nurse (RN)12 to 24 units/month25 to 56 units/monthPeer Support10 to 20 units/month21 to 30 units/month11909011HCBS-AMH Pre-EngagementHBCS-AMH Recovery ManagementRecovery Management Conversion Services FeeRecovery Management Transitional Day RateRecovery Management Transitional FeeRespite Care In-Home1 to 96 units/monthRespite Care Out-of-Home 24 Hour ResidentialHabilitation Home1 unit/month3 unit/monthRespite Care Out-of-Home Adult Foster Care Home1 unit/month3 unit/monthRespite Care Out-of-Home Licensed Assisted LivingFacility1 unit/month3 unit/monthRespite Care Out-of-Home Nursing Facility1 unit/month3 unit/month1110 to 20 units/month21 to 39 units/monthSubstance Use Disorder Services AssessmentSubstance Use Disorder Services Group97 to 288 units/month19
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesHCBS-AMH ServiceSubstance Use Disorder Services IndividualSupervised Living ServicesSupported Home LivingTransition Assistance ServicesTransition Assistance Services Requisition FeeTransportationStandard Anticipated UnitsHigh Need Utilization100 to 145 units/month146 to 192units/monthDailyN/A128 to 250 units/month251 to 744units/month 1500-SHL, 500- HH/SL/AL 2500-SHL, 1,000- HH/SL/AL11303 to 400 miles/month401 to 500miles/month20
Home and Community-Based Services-Adult Mental HealthBilling GuidelinesNOTES:Adaptive Aids, Minor Home Modifications, Transition Assistance Services and FlexibleFunds do not have rates assigned to them.When completing invoices, on the Encounter Data Tab, document the actual cost ofthe service in the Unit Rate column.If Minor Home Modifications, and Adaptive Aids cost is over 500.00, three bids mustbe obtained and submitted for review prior to purchase.Room and board, normal household expenses and items not related to amelioration ofthe person’s disability are not included.There is a 2,000 cost cap per participant for the transition event into their residence(including, but not limited, to supported home living and Host Home/CompanionCare).There is a 1,000 cost cap per participant for the transition event into a host home,supe
Licensed Practitioner of the Healing Arts (LPHA) A person who is a physician, a licensed professional counselor, a licensed clinical social worker, a licensed psychologist, an advanced practice nurse, or a licensed marriage and family therapist. Licensed Vocati
