Library: Policy

317:30-5-596. Coverage by category

Revised 9-15-15

        Payment is made for behavioral health case management services as set forth in this Section.

• (1) Payment is made for services rendered to SoonerCare members as follows:

  • (A) Description of behavioral health case management services. Services under behavioral health case management are not comparable in amount, duration and scope. The target group for behavioral health case management services are persons under age 21 who are in imminent risk of out-of-home placement for psychiatric or substance abuse reasons or are in out-of-home placement due to psychiatric or substance abuse reasons and chronically and/or severely mentally ill adults who are institutionalized or are at risk of institutionalization. All behavioral health case management services will be subject to medical necessity criteria.

    • (i) Behavioral health case management services are provided to assist eligible individuals in gaining access to needed medical, social, educational and other services essential to meeting basic human needs. The behavioral health case manager provides assessment of case management needs, development of a case management care plan, referral, linkage, monitoring and advocacy on behalf of the member to gain access to appropriate community resources. The behavioral health case manager must monitor the progress in gaining access to services and continued appropriate utilization of necessary community resources. Behavioral case management is designed to promote recovery, maintain community tenure, and to assist individuals in accessing services for themselves following the case management guidelines established by ODMHSAS. In order to be compensable, the service must be performed utilizing the Strengths Based model of case management. This model of case management assists individuals in identifying and securing the range of resources, both environmental and personal, needed to live in a normally interdependent way in the community. The focus for the helping process is on strengths, interests, abilities, knowledge and capacities of each person, not on their diagnosis, weakness or deficits. The relationship between the service member and the behavioral health case manager is characterized by mutuality, collaboration, and partnership. Assistive activities are designed to occur primarily in the community, but may take place in the behavioral health case manager's office, if more appropriate. The community based behavioral health case management agency will coordinate with the member and family (if applicable) by phone or face-to-face, to identify immediate needs for return to home/community no more than 72 hours after notification that the member/family requests case management services. For member's discharging from a higher level of care than outpatient, the higher level of care facility is responsible for scheduling an appointment with a case management agency for transition and post discharge services. The case manager will make contact with the member and family (if applicable) for transition from the higher level of care than outpatient back to the community, within 72 hours of discharge, and then conduct a follow-up appointment/contact within seven days. The case manager will provide linkage/referral to physicians/medication services, counseling services, rehabilitation and/or support services as described in the case management service plan. Case Managers may also provide crisis diversion (unanticipated, unscheduled situation requiring supportive assistance, face-to-face or telephone, to resolve immediate problems before they become overwhelming and severely impair the individual's ability to function or maintain in the community) to assist member(s) from progression to a higher level of care. During the follow-up phase of these referrals or links, the behavioral health case manager will provide aggressive outreach if appointments or contacts are missed within two business days of the missed appointments. Community/home based case management to assess the needs for services will be scheduled as reflected in the case management service plan, but not less than one time per month. The member/parent/guardian has the right to refuse behavioral health case management and cannot be restricted from other services because of a refusal of behavioral health case management services.

    • (ii) An eligible member/parent/guardian will not be restricted and will have the freedom to choose a behavioral health case management provider as well as providers of other medical care.

    • (iii) In order to ensure that behavioral health case management services appropriately meet the needs of the member and family and are not duplicated, behavioral health case management activities will be provided in accordance with an individualized plan of care.

    • (iv) The individual plan of care must include general goals and objectives pertinent to the overall recovery of the member's (and family, if applicable) needs. Progress notes must relate to the individual plan of care and describe the specific activities to be performed. The individual plan of care must be developed with participation by, as well as, reviewed and signed by the member, the parent or guardian (if the member is under 18), the behavioral health case manager, and a Licensed Behavioral Health Professional as defined in OAC 317:30-5-240(d).

    • (v) SoonerCare reimbursable behavioral health case management services include the following:

      • (I) Gathering necessary psychological, educational, medical, and social information for the purpose of individual plan of care development.

      • (II) Face-to-face meetings with the member and/or the parent/guardian/family member for the implementation of activities delineated in the individual plan of care.

      • (III) Face-to-face meetings with treatment or service providers, necessary for the implementation of activities delineated in the individual plan of care.

      • (IV) Supportive activities such as non face-to-face communication with the member and/or parent/guardian/family member.

      • (V) Non face-to-face communication with treatment or service providers necessary for the implementation of activities delineated in the individual plan of care.

      • (VI)Monitoring of the individual plan of care to reassess goals and objectives and assess progress and or barriers to progress.

      • (VII) Crisis diversion (unanticipated, unscheduled situation requiring supportive assistance, face-to-face or telephone, to resolve immediate problems before they become overwhelming and severely impair the individual's ability to function or maintain in the community) to assist member(s) from progression to a higher level of care.

      • (VIII) Transitioning from institutions to the community. Behavioral Health Case Management is available to individuals transitioning from institutions to the community (except individuals ages 22 to 64 who reside in an institution for mental diseases (IMD) or individuals who are inmates of public institutions). Individuals are considered to be transitioning to the community during the last 30 consecutive days of a covered institutional stay. This time is to distinguish case management services that are not within the scope of the institution's discharge planning activities from case management required for transitioning individuals with complex, chronic, medical needs to the community. Transition services provided while the individual is in the institution are to be claimed as delivered on the day of discharge from the institution.

  • (B) Levels of Case Management.

    • (i) Basic Case Management/Resource Coordination. Resource coordination services are targeted to adults with serious and persistent mental illness and children and adolescents with mental illness or serious emotional disturbance, and their families, who need assistance in accessing, coordination, and monitoring of resources and services. Services are provided to assess an individual's strengths and meet needs in order to achieve stability in the community. Standard managers have with caseloads of 30 - 35 members.

    • (ii) Intensive Case Management (ICM)/Wraparound Facilitation Case Management (WFCM). Intensive Case Management is targeted to adults with serious and persistent mental illness (including members in PACT programs) and Wraparound Facilitation Case Management is targeted to children with serious mental illness and emotional disorders (including members in a System of Care Network) who are deemed high risk and in need of more intensive CM services. It is designed to ensure access to community agencies, services, and people whose functions are to provide the support, training and assistance required for a stable, safe, and healthy community life, and decreased need for higher levels of care. To produce a high fidelity wraparound process, a facilitator can facilitate between 8 and 10 families. To ensure that these intense needs are met, case manager caseloads are limited between 10-15 caseloads. The ICM shall be a Certified Behavioral Health Case Manager, have a minimum of 2 years Behavioral Health Case Management experience, crisis diversion experience, must have attended the ODMHSAS 6 hours ICM training, and 24 hour availability is required.

  • (C) Excluded Services. SoonerCare reimbursable behavioral health case management does not include the following activities:

    • (i) Physically escorting or transporting a member or family to scheduled appointments or staying with the member during an appointment; or

    • (ii) Managing finances; or

    • (iii) Providing specific services such as shopping or paying bills; or

    • (iv) Delivering bus tickets, food stamps, money, etc.; or

    • (v) Counseling, rehabilitative services, psychiatric assessment, or discharge planning; or

    • (vi) Filling out forms, applications, etc., on behalf of the member when the member is not present; or

    • (vii) Filling out SoonerCare forms, applications, etc.;

    • (viii) Mentoring or tutoring;

    • (ix) Provision of behavioral health case management services to the same family by two separate behavioral health case management agencies;

    • (x) Non face-to-face time spent preparing the assessment document and the service plan paperwork;

    • (xi) monitoring financial goals;

    • (xii) services to nursing home residents;

    • (xiii) psychotherapeutic or rehabilitative services, psychiatric assessment, or discharge; or

    • (xix) services to members residing in ICF/IID facilities.

  • (D) Excluded Individuals. The following SoonerCare members are not eligible for behavioral health case management services:

    • (i) Children/families for whom behavioral health case management services are available through OKDHS/OJA staff without special arrangements with OKDHS, OJA, and OHCA;

    • (ii) Members receiving Residential Behavior Management Services (RBMS) in a foster care or group home setting unless transitioning into the community;

    • (iii) Residents of ICF/IID and nursing facilities unless transitioning into the community;

    • (iv) Members receiving services under a Home and Community Based services (HCBS) waiver program.

  • (E) Case management services provided to Medicare eligible members should be filed directly with the fiscal agent.

  • (F) Documentation requirements. The service plan must include general goals and objectives pertinent to the overall recovery needs of the member. Progress notes must relate to the service plan and describe the specific activities performed. Behavioral health case management service plan development is compensable time if the time is spent communicating with the participation by, as well as, reviewed and signed by the member, the behavioral health case manager, and a licensed behavioral health professional as defined at OAC 317:30-5-240.3(a). All behavioral health case management services rendered must be reflected by documentation in the records. In addition to a complete behavioral health case management service, plan documentation of each session must include but is not limited to:

    • (i) date;

    • (ii) person(s) to whom services are rendered;

    • (iii) start and stop times for each service;

    • (iv) original signature or the service provider (original signatures for faxed items must be added to the clinical file within 30 days);

    • (v) credentials of the service provider;

    • (vi) specific service plan needs, goals and/or objectives addressed;

    • (vii) specific activities performed by the behavioral health case manager on behalf of the child related to advocacy, linkage, referral, or monitoring used to address needs, goals and/or objectives;

    • (viii) progress and barriers made towards goals, and/or objectives;

    • (ix) member (family when applicable) response to the service;

    • (x) any new service plan needs, goals, and/or objectives identified during the service; and

    • (xi) member satisfaction with staff intervention.

  • (G) Case Management Travel Time. The rate for case management services assumes that the case manager will spend some amount of time traveling to the member for the face-to-face service. The case manager must only bill for the actual face-to-face time that they spend with the member and not bill for travel time. This would be considered duplicative billing since the rate assumes the travel component already.