20 CAR Part 645 — Rehabilitative Services for Youth and Children Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 645 Rehabilitative Services for Youth and Children Provider Manual {#sec-20-car-pt.-645 omnilex-key=us-ar-regs-official--title-20-part-645--20 CAR pt. 645}

Rehabilitative Services for Youth and Children Section II Section II-1 SECTION II - REHABILITATIVE SERVICES FOR YOUTH AND CHILDREN (RSYC) CONTENTS

200.000 REHABILITATIVE SERVICES FOR YOUTH AND CHILDREN (RSYC) GENERAL INFORMATION

201.000 Introduction 202.000 Arkansas Medicaid Participation Requirements for RSYC 202.100 Billing Providers of RSYC Services for Youth in the Custody or Care of Arkansas Division of Youth Services (DYS) 202.110 Performing Providers of RSYC Services for Youth 202.200 Billing Providers of RSYC Services for Children in the Custody or Care of Arkansas Division of Children and Family Services (DCFS) 202.210 Performing Providers of RSYC Services for Children 202.300 Rehabilitative Services for Youth and Children Providers in Bordering and Non- Bordering States 203.000 Primary Care Physician (PCP) Referral 210.000 PROGRAM COVERAGE 211.000 Coverage of Services 211.100 RSYC Services for Youth 211.200 RSYC Services for Children 212.000 Performing Provider Qualifications 212.100 RSYC Services for Youth 212.110 Service Settings for RSYC Services for Youth 212.200 RSYC Services for Children 212.210 Service Settings for RSYC Services for Children 213.000 Exclusions 214.000 Need for Services 215.000 Reserved 216.000 Documentation 217.000 Description of Services 217.100 Covered RSYC Services for Youth 217.200 Covered RSYC Services for Children 218.000 Benefit Limits 219.000 Electronic Signatures 240.000 PRIOR AUTHORIZATION 240.100 Prior Authorization for Rehabilitative Services for Youth 250.000 REIMBURSEMENT 250.100 Method of Reimbursement 250.101 Fee Schedule 260.000 BILLING PROCEDURES 261.000 Introduction to Billing 262.000 Rehabilitative Services for Youth and Children (RSYC) Billing Codes 262.100 Division of Youth Services (DYS) Special Billing Codes 262.200 Division of Children and Family Services (DCFS) Special Billing Codes

200.000 REHABILITATIVE SERVICES FOR YOUTH AND CHILDREN (RSYC) GENERAL INFORMATION

201.000 Introduction 7-1 -05 Medicaid (Medical Assistance) is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Reimbursement may be

Rehabilitative Services for Youth and Children Section II Section II-2 made for Rehabilitative Services for Youth and Children (RSYC) when provided to eligible Medicaid beneficiaries by qualified providers. 202.000 Arkansas Medicaid Participation Requirements for RSYC

202.100 Billing Providers of RSYC Services for Youth in the Custody or Care of Arkansas Division of Youth Services (DYS) 10-13-03 Billing providers (DYS) of Rehabilitative Services for Youth under 21 years of age must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual to be eligible for participation in the Arkansas Medicaid Program. 202.110 Performing Providers of RSYC Services for Youth 10-13-03 Performing providers of Rehabilitative Services for Youth under 21 years of age must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible for participation in the Arkansas Medicaid Program: The performing provider must be certified by the Division of Youth Services as having programs and professional staff capable of delivering the rehabilitative services offered under the Arkansas State Plan. A copy of the applicant’s certification must accompany the provider application and the Medicaid contract. 202.200 Billing Providers of RSYC Services for Children in the Custody or Care of Arkansas Division of Children and Family Services (DCFS) 10-13-03 Billing providers (DCFS) of Rehabilitative Services for Children under 21 years of age must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual to be eligible for participation in the Arkansas Medicaid Program. 202.210 Performing Providers of RSYC Services for Children 10-13-03 Performing providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible for the Arkansas Medicaid Program: The performing provider of RSYC services for children must be certified by the Division of Children and Family Services as having programs and professional staff capable of delivering the rehabilitative services offered under the Arkansas State Plan. A copy of the applicant’s certification must accompany the provider application and the Medicaid contract. 202.300 Rehabilitative Services for Youth and Children Providers in Bordering and Non-Bordering States 10-13-03 The Arkansas Medicaid Rehabilitative Services for Youth and Children Program is limited to in- state providers only. 203.000 Primary Care Physician (PCP) Referral 10-13-03 PCP referral is not required for RSYC Services.

210.000 PROGRAM COVERAGE

211.000 Coverage of Services

211.100 RSYC Services for Youth 10-13-03

Rehabilitative Services for Youth and Children Section II Section II-3 Rehabilitative Services for Youth and Children (RSYC) are available to youth under age 21 in the Child Health Services (EPSDT) Program and in the custody or care of the Arkansas Division of Youth Services (DYS). RSYC medically necessary services are designed to: A. Ameliorate psychological or emotional problems of youth that contribute to delinquent behavior and to placement or to the increased risk of placement in the DYS system and B. Restore psychological or emotional functioning of the youth to assist him or her in achieving or maintaining his or her highest functioning level. RSYC services for youth are covered by Medicaid when deemed medically necessary, when provided in a setting consistent with the plan of care, and when care is provided through a certified provider. 211.200 RSYC Services for Children 10-13-03 Rehabilitative Services for Youth and Children (RSYC) are available to children in the Child Health Services (EPSDT) Program and in the custody or care of Arkansas Division of Children and Family Services (DCFS). The specific services are determined to be medically necessary and included in a child’s treatment plan prepared by a qualified provider of rehabilitative services to children. These services are designed to: A. Ameliorate psychological or emotional problems related to neglect and/or abuse, B. Restore psychological or emotional functioning impaired by the problems related to neglect and/or abuse and C. Assist the child in improving or maintaining his or her highest functioning level. Services are covered by Medicaid when provided according to the plan of care and when care is provided by professional state licensed and/or certified psychiatrists, psychologists, counselors, and social workers acting within the scope of their practice as defined by state law and/or regulations. 212.000 Performing Provider Qualifications

212.100 RSYC Services for Youth 3-1 -05 RSYC performing providers of services for youth must utilize “Qualified Professionals” to provide therapy and diagnostic services. A qualified professional is defined as a Master’s level professional or Bachelor’s level professional supervised by a Master’s level clinician, or a Master’s level psychologist supervised by a Ph.D. level psychologist who is licensed in the State of Arkansas in either psychology, social work or professional counseling. To be considered as a “Qualified Professional” the individual must be in good standing with the board by which he or she is licensed. Rehabilitative Services for Youth and Children providers of Therapeutic Foster Care services to youth must utilize specially trained (or qualified) foster parents. Caregivers who provide this service in their homes, if not specially trained, must be specifically qualified to provide the service because they have an educational or a professional background that attests to qualification equal to or greater than that of caregivers who have received special training. Rehabilitative services for youth will be provided only through qualified providers and provider agencies. Qualified rehabilitative services for youth provider agencies must meet the following criteria. Care is provided by qualified therapists, other qualified professionals and staff, qualified by experience and/or training, of certified rehabilitative services providers for youth. Rehabilitative services providers for youth must:

Rehabilitative Services for Youth and Children Section II Section II-4 A. Be certified by the State Youth Services Agency as having programs and professional staff capable of delivering the rehabilitative services offered under the Medicaid State Plan, B. Have full access to all pertinent records concerning the youth’s needs for services including records of the Arkansas District Courts, local Youth Service Agencies, and State Youth Services Agency, C. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population, D. Have a minimum of one year’s experience in providing rehabilitative services for youth, E. Have an administrative capacity to ensure quality of services in accordance with State and Federal requirements, F. Have a financial management capacity and system that provides documentation of services and costs in conformity with generally accepted accounting principles, G. Have a capacity to document and maintain individual case records in accordance with State and Federal requirements, and H. Have a demonstrated ability to meet all State and Federal laws governing the participation of providers in the State Medicaid program, including the ability to meet Federal and State requirements for documentation, billing and audits. 212.110 Service Settings for RSYC Services for Youth 10-13-03 RSYC for youth will be provided in the least restrictive setting appropriate for the service, the youth’s assessed condition, and plan of care. Services shall be provided to youth in one or more of the following settings: A. Non-residential services provided to youth who reside in a family home setting will be provided either in the youth’s home or in the customary place of business of a qualified provider. B. Residential services provided to youth who reside outside of a family home will be provided in an appropriately state licensed and/or certified setting including:

1. Emergency shelter facilities licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services,
2. Residential treatment facilities licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services and
3. Therapeutic foster and group homes licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services. 212.200 RSYC Services for Children 10-13-03 RSYC services for children will be provided only through qualified provider agencies. Qualified provider agencies must meet the following criteria: A. Have full access to all pertinent records concerning the child’s needs for services including records of the Arkansas District Courts, local Children’s Service Agencies, and State Child and Family Services Agency,

Rehabilitative Services for Youth and Children Section II Section II-5 B. Have established referral systems and demonstrated linkages and referral ability with community resources required by the target population, C. Have a minimum of one year experience in providing all core elements of rehabilitative services for children, D. Have an administrative capacity to ensure quality of services in accordance with state and federal requirements, E. Have a financial management capacity and system that provides documentation of services and costs, in conformity with generally accepted accounting principles, F. Have a capacity to document and maintain individual case records in accordance with state and federal requirements and G. Have a demonstrated ability to meet all state and federal laws governing the participation of providers in the Arkansas Medicaid Program, including the ability to meet federal and state requirements for documentation, billing and audits. 212.210 Service Settings for RSYC Services for Children 10-13-03 RSYC for children will be provided in the least restrictive setting appropriate for the service, the child’s assessed condition, and plan of care. Services shall be provided to children in one or more of the following settings: A. Non-residential services provided to youth who reside in a family home setting must be provided either in the home or in the customary place of business of a qualified provider. B. Residential services provided to youth who reside outside of a family home will be provided in an appropriately state licensed and/or certified therapeutic foster home licensed and/or certified in accordance with the Minimum Licensing Standards for Child Welfare Agencies adopted by the Child Welfare Agency Review Board and the Arkansas Department of Human Services. 213.000 Exclusions 10-13-03 A. Rehabilitative Services for children are not available to Aid Category 01, ARKids First-B participants. B. Medicaid will not reimburse for RSYC services provided in the following settings:

1. Nursing facilities,
2. Intermediate care facilities for the mentally retarded and
3. Institutions for the treatment of mental diseases. 214.000 Need for Services 10-13-03 Need for services is based on assessments performed by the Division of Youth Services or the Division of Children and Family Services, as appropriate, on diagnosis and evaluations performed by RSYC providers and/or on a physician’s recommendation for treatment. 215.000 Reserved 11-1-09 216.000 Documentation 10-13-03 Rehabilitative Services for Youth and Children performing providers must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the Arkansas Division of Youth Services, the Arkansas Division of Children and Family Services, the

Rehabilitative Services for Youth and Children Section II Section II-6 State Medicaid Fraud Unit and representatives of the Department of Health and Human Services and their authorized agents or officials, a copy of the provider’s license and/or certification required for provider certification and other records as requested. The Rehabilitative Services for Youth and Children performing provider must develop and maintain sufficient written documentation to support each service for which billing is made. This documentation must consist of, at a minimum, material that includes: A. Assessments, diagnosis(es) and evaluations indicating a need for treatment and/or a physician’s recommendation for treatment. B. When applicable, a copy of the original and all updates of the individual’s case or treatment plan. C. The specific services rendered. D. The date and actual clock time for the service rendered. E. The name of the provider agency, if applicable, and of the person providing the service. F. The place of service. G. The number of units billed. All entries must be signed or initialed and dated by the qualified professional or other provider representative who provided the service, along with the individual’s title. The documentation must be kept in the beneficiary’s case file. Failure by the provider to furnish records upon request may result in the imposition of sanctions. The provider must make all documents available to representatives of the Division of Medical Services Medicaid Field Audit Unit, and the Division of Youth Services, or the Division of Children and Family Services at the time of an audit. All documentation must be available at the provider’s place of business. When a recoupment is necessary, the provider will be allowed only thirty calendar days after the date of the recoupment notice to submit additional documentation. Additional documentation will not be accepted if it is received after the 30th day. 217.000 Description of Services 10-13-03 The following sections contain descriptions of the covered services in this program. The procedure codes for these services are listed in Section 260.000 of this manual. 217.100 Covered RSYC Services for Youth 10-13-03 The following RSYC services for youth are billable on a per unit basis. See Section 250.100 for unit definitions and reimbursement methodology. See Section 262.000 for billing instructions. Diagnosis and Evaluation This service provides assessment of the nature and extent of a youth’s physical, emotional, educational and behavioral problems, and provides recommendations for treatment strategies to remedy the identified problems. Allowable components include social assessment, psychological assessment, psychiatric evaluation, consultation with a referring agency, and a medical evaluation if the assessment indicates a physical association with the emotional and/or behavioral problem(s). Individual Therapy (includes family therapy with youth and consultation with referral source) This service provides for a therapeutic relationship between the client and a qualified therapist for the purpose of accomplishing, through the use of various counseling techniques, specific changes that are identified as goals in plan of care.

Rehabilitative Services for Youth and Children Section II Section II-7 Group Therapy A direct service contact between a group of patients and a qualified therapist for the purpose of accomplishing changes that are identified as goals in the case plan through the use of various counseling techniques. Emergency Shelter Services This residential service provides services for youth whose circumstances or behavioral problems necessitate immediate removal from their homes, or for youth released from youth service facilities who need temporary placement in the community until long-term residential arrangements can be made. Services include additional evaluation of the nature and extent of a youth’s emotional and behavioral problems, including social assessment, psychological evaluation, psychiatric evaluation and consultation with the referring agency, and interventions to address the youth’s emotional and behavioral problems. Therapeutic Foster Care This residential service provides intensive therapeutic care for youth. The service is provided in family homes that operate within a comprehensive residential treatment system or as an adjunct to a mental health treatment program and for which a fee is paid to specially trained foster families. Individuals who receive this service have physical, emotional, or behavioral problems, which cannot be remedied in their own home, in a routine foster parenting situation or in a residential program. Therapeutic Group Home This residential service provides twenty-four hour per day intensive therapeutic care provided in a small group home setting for youth with emotional and/or behavior problems, which cannot be remedied by less intensive treatment, as diagnosed by a qualified professional. This program is offered to prepare a juvenile for less intensive treatment, independent living or to return to the community. Residential Treatment * (excluding room and board) This residential service provides twenty-four hour per day treatment service available for up to one year for a youth whose emotional and/or behavioral problems, as diagnosed by a qualified professional, cannot be remedied in his or her own home. Residential treatment services require the formulation and implementation of an individualized treatment plan with time-framed, measurable objectives for each youth. *Residential facilities providing RSYC services for youth must meet the Minimum Licensing Standards for Child Welfare Agencies issued by the Child Welfare Agency Review Board and the Arkansas Department of Human Services. 217.200 Covered RSYC Services for Children 10-13-03 The following RSYC services for children are billable on a per unit basis. See Section 250.100 for unit definitions and reimbursement methodology. See Section 262.000 for billing instructions. Psychiatric Diagnostic Interview Examination This interview includes the initial assessment of a child’s service needs. Assessment, Reassessment and Plan of Care Development Assessment, reassessment and plan of care (PoC) development includes the initial assessment and a reassessment of a child’s service needs and the development of a PoC to address those needs. This is a restricted service and must be authorized by the Division of Mental Health Services (DMHS). The child for whom the service is requested must meet the criteria of Serious Emotional Disturbance (SED).

Rehabilitative Services for Youth and Children Section II Section II-8 A. The assessment and reassessment shall:

1. Be based on informed clinical opinion;
2. Be conducted by a team of professionals trained to utilize appropriate evaluative methods and procedures and acting within the scope of their practice or responsibility as defined in state law and/or regulations and
3. Include an evaluation of the child’s cognitive development, social and emotional development and adaptive development. B. The Plan of Care (PoC) shall contain:
4. A written plan using the information derived from the evaluation and assessment;
5. A statement regarding the child’s present level of functioning in the domains examined in the evaluation and assessment;
6. A statement regarding the specific services and supports necessary to meet the unique needs of the child, the setting in which the services are to be delivered, the frequency and method of delivery, and the anticipated duration of services;
7. A statement regarding the persons responsible for implementing the plan of care and
8. A statement regarding the functional outcomes expected to be achieved through the provision of services and supports. Periodic Review of Plan of Care (PoC) The periodic review of the plan of care (PoC) must be completed at least every 90 days. The purpose of the review is to determine the:
   1. Patient’s progress toward the rehabilitative treatment and case objective;
   2. Appropriateness of the rehabilitative services provided and
   3. Need for the enrolled patient’s continued participation in the RSYC Program.
   Therapeutic Foster Care Therapeutic Foster Care is a residential service provided to children whose plan of care indicates the need for a structured and consistent home environment in which to learn to manage their behavior. This twenty-four hour per day service consists of face-to-face interventions with a child to assist the child in understanding the consequences of inappropriate behaviors and adhering to a behavioral routine that minimizes inappropriate behaviors and their consequences. This service is provided for the purpose of the development, restoration, and/or maintenance of the skills to manage his or her mental or emotional condition. Residential Treatment (excluding room and board) Residential treatment provides twenty-four hour per day treatment to children whose psychological or emotional problems related to neglect and/or abuse or behavioral problems can best be restored by residential treatment in accordance with the child’s plan of care. This service is designed to: A. Assist the child in improving or maintaining his or her highest functioning level through individual and group therapeutic interventions; B. Improve or maintain the skills needed to safely and securely interact with other persons, through symptom management; C. Allow the child to identify and minimize the negative effects of psychiatric or emotional symptoms which interfere with the child’s personal development and community integration and

Rehabilitative Services for Youth and Children Section II Section II-9 D. Develop, restore and/or maintain the child’s mental or emotional growth through supportive counseling. 218.000 Benefit Limits 11-1-17 No benefit limits apply to rehabilitative services for youth and children. Exception: DCFS periodic review of plan of care, H0032, is limited to two (2) units per day. 219.000 Electronic Signatures 10-8-10 Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.

240.000 PRIOR AUTHORIZATION

240.100 Prior Authorization for Rehabilitative Services for Youth 10-14-16 Prior authorization is required by the current contractor for youth for the following services:

National Code Code Description 90832 INDIVIDUAL PSYCHOTHERAPY 1 unit = 15 minutes 90853 GROUP PSYCHOTHERAPY 1 unit = 15 minutes

View or print current contractor contact information.

250.000 REIMBURSEMENT

250.100 Method of Reimbursement 10-13-03 Reimbursement is based on the actual cost of rehabilitative services billed and approved for payment. For residential based services, the daily cost for room and board is deducted to determine net reimbursable costs. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying the beneficiary’s eligibility for Medicaid prior to rendering services. Non-residential rehabilitative services for youth and children must be billed on a per unit basis. One unit equals 15 minutes unless otherwise stated in the Billing Procedures section of this manual. One (1) unit = 5 - 15 minutes Two (2) units = 16 - 30 minutes Three (3) units = 31 - 45 minutes Four (4) units = 46 - 60 minutes Providers may bill the total units of service for a single date of service but may not bill the total units of service for spanning dates of service. For example, a qualified professional may provide therapy services to an eligible youth on Monday and then again on Tuesday. The Rehabilitative Services for Youth and Children provider may bill for the total amount of time spent on Monday

Rehabilitative Services for Youth and Children Section II Section II-10 and a separate total amount of time spent on Tuesday, but may not bill for the total amount of time spent both days as a single date of service. Residential rehabilitative services must be billed on a daily basis. For residential services, one unit equals one day of service. Providers may collectively bill services up to one calendar month. For example, a rehabilitative services provider of residential treatment that serves an eligible youth for the entire month of July may bill the entire month as July 1 through July 31, for a total of 31 days of service or 31 units. 250.101 Fee Schedule 12-1-12 Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://medicaid.mmis.arkansas.gov/ under the provider manual section. The fees represent the fee-for-service reimbursement methodology. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.

260.000 BILLING PROCEDURES

261.000 Introduction to Billing 10-13-03 The purpose of this section is to explain the procedures for billing in the Arkansas Medicaid Program. For Rehabilitative Services for Youth and Children (RSYC), the billing providers are the Division of Children and Family Services (DCFS) or the Division of Youth Services (DYS). However, the performing provider must follow the internal procedures of the respective Division to report the service provided. 262.000 Rehabilitative Services for Youth and Children (RSYC) Billing Codes 10-13-03 The following pages contain a listing of Arkansas Medicaid Rehabilitative Services for Youth and Children (RSYC) Codes. The procedure codes which are covered for the Division of Youth Services (DYS) and the Division of Children and Family Services (DCFS) are listed separately. 262.100 Division of Youth Services (DYS) Special Billing Codes 9-1 -13 The following pages contain a listing of Arkansas Medicaid Rehabilitative Services for Youth and Children (RSYC) Codes that pertain to services covered by the Division of Youth Services (DYS). It is important to use the Medicaid code listing. All codes must have five digits. NOTE: Effective for claims received on or after December 5, 2005, modifier UB must be used as described below.

Procedure Code Required Modifier

Description 96101 UA, UB PSYCHOLOGICAL TESTING BATTERY This code will only be used for the retroactive billing period. 1 unit = test battery

Rehabilitative Services for Youth and Children Section II Section II-11 Procedure Code Required Modifier

Description H2020 — EMERGENCY SHELTER 1 unit = 1 day H2020 U1 THERAPEUTIC FOSTER CARE 1 unit = 1 day H2020 U2 THERAPEUTIC GROUP HOME 1 unit = 1 day H2020 U4 RESIDENTIAL TREATMENT SERVICES 1 unit = 1 day 90791 — DIAGNOSIS AND EVALUATION 1 unit = 15 minutes 90832 U1 INDIVIDUAL PSYCHOTHERAPY 1 unit = 15 minutes 90853 — GROUP PSYCHOTHERAPY 1 unit = 15 minutes

262.200 Division of Children and Family Services (DCFS) Special Billing Codes 9-1 -13 The following pages contain a listing of Arkansas Medicaid Rehabilitative Services for Youth and Children (RSYC) codes that pertain to services covered by the Division of Children and Family Services (DCFS). It is important to use the Medicaid code listing. All codes must have five digits.

Procedure Code Required Modifier

Description 90792 — PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION 1 unit = 1 visit T1023 U1 ASSESSMENT, REASSESSMENT AND PLAN OF CARE DEVELOPMENT 1 unit = 1 visit H0032 U1 PERIODIC REVIEW OF PLAN OF CARE 1 unit = 15 minutes. Maximum of 2 units per day. H2020 U1 THERAPEUTIC FOSTER CARE 1 unit = 1 day H2020 U1 RESIDENTIAL TREATMENT SERVICES 1 unit = 1 day