Rehabilitative Behavioral Health Services Changes

 

Effective March 1, 2015, the South Carolina Department of Health and Human Services (SCDHHS) will implement the following changes to the Rehabilitative Behavioral Health Services (RBHS) policy. These changes apply to fee for service RBHS only.

  1. Medical Necessity and Prior Authorizations

Prior authorization (PA) is required for Psychosocial Rehabilitative Services (PRS), Behavior Modification (BMOD) and Family Support (FS) for beneficiaries 0-21 that are receiving these services from private providers. The PA process will consist of the submission of a Diagnostic Assessment (DA) and Child and Adolescent Level of Care Utilization System (CALOCUS), performed by an independent third party Licensed Practitioner of the Healing Arts (LPHA), who is not affiliated with the receiving private RBHS provider. The CALOCUS must be completed by a clinician with a CALOCUS provider certification. KEPRO, the Quality Improvement Organization (QIO), for SCDHHS, will review submitted documentation utilizing medical necessity criteria for the aforementioned services contained within the RBHS provider manual.

Prior authorization is required for PRS and FS for beneficiaries 22+ who are receiving these services from private providers. The PA process will consist of the submission of a DA performed by an independent third party LPHA who is not affiliated with the receiving private RBHS provider. The QIO will review submitted documentation utilizing medical necessity criteria for the aforementioned services contained within the RBHS provider manual.

Prior authorization is required for all beneficiaries with dates of service on or after March 1, 2015. Beneficiaries receiving PRS, BMOD or FS on dates of service prior to March 1 have until June 1, 2015 to receive authorization in order to continue to provide service to current beneficiaries, if medically necessary.

All prior authorizations cover up to 90 day periods (0-21) and 180 day periods (22+) for each discrete service. Authorization(s) for continued service must be submitted to the QIO, ten (10) business days prior to the expiration of the current authorization. The QIO will process and either approve or deny service authorization(s) within five (5) business days of receipt, pending complete submission of all required information. When medically necessary, requests for continued authorization of up to 90 days (0-21) and 180 days (22+) must be sent to the QIO ten (10) business days prior to the expiration of the initial authorization.

Private RBHS providers who receive referrals from state agencies, must adhere to the service type and frequency limit contained in the referral. Should the treatment needs change, the private provider must receive confirmation from the referring state agency to change the service type or frequency.

Private RBHS providers serving children and adolescents in foster care must receive prior authorization from the South Carolina Department of Social Services.

Exclusion: State agencies directly providing RBHS, and all providers delivering services to children in foster care, are exempt from this requirement.

 

  1. Staff Credentials

Effective July 1, 2015, a Bachelor’s Degree or above is required for the provision of PRS, BMOD and FS.

Exclusion: Providers’ staff directly serving children in foster care are exempt from this requirement.

  1. Staff to Client Ratio (no exclusions)

The staff to client (both Medicaid and non-Medicaid individuals) ratio of PRS must not exceed 1:8 for both adults and children. Only staff who meet credentialing requirements for PRS are considered for the 1:8 ratio.

  1. Frequency Limits (no exclusions)

Daily frequency limits are as follows:

  • PRS 24 units (15 minutes per unit)

  • FS 32 units (15 minutes per unit)

  • BMOD 32 units (15 minutes per unit)

Requests for services in excess of these limits may be submitted to the SCDHHS Division of Behavioral Health in accordance with the guidelines in the RBHS provider manual: Jeffgab@scdhhs.gov

 

  1. Reimbursement Rates and Modifier Changes for PRS

These reimbursement rates are effective for service dates on or after March 1, 2015:

Individual Old Modifier   New Rate New HCPCS Modifier
H2017 AF Physician / Psychiatrist n/a n/a
HP Doctoral Level (MD) n/a n/a
AM Physician Team Member (PA) n/a n/a
SA Nurse Practitioner (APRN) n/a n/a
AH Licensed Psychologist $13.02 U1
HO Master's Level $ 9.93 U2
HN Bachelor's level $ 9.00 U3
TD Registered Nurse (RN) $10.85 U4
TE Licensed Practical Nurse (LPN) n/a n/a
HM < Bachelor’s degree (TFC only) $5.98 U5

Group Old Modifier   New Rate New HCPCS Modifier
H2017 AF Physician / Psychiatrist n/a n/a
HP Doctoral Level (MD) n/a n/a
AM Physician Team Member (PA) n/a n/a
SA Nurse Practitioner (APRN) n/a n/a
AH Licensed Psychologist $3.26 U6
HO Master's Level $2.48 U7
HN Bachelor's level $2.25 U8
TD Registered Nurse (RN) $2.71 U9
TE Licensed Practical Nurse (LPN) n/a n/a
HM < Bachelor’s degree (TFC only) $1.50 UA

 

Provider Training

KEPRO will be providing web based training on the Prior Authorization Process on the following dates:

  • Tuesday, February 24, 9:00am-11:00am

  • Wednesday, February 25, 1:00pm-3:00pm

  • Friday, February 27, 1:00pm-3:00pm

To join the training please call KEPRO at 866-754-2932 code: 8572016139 or click on the following link:

http://kepro.adobeconnect.com/r5ene08wwfi/

Please contact the Provider Service Center at (888) 289-0709 for any questions regarding the Medicaid fee for services policies indicated in this bulletin.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

For answers to commonly asked questions on these RBHS service changes, please visit  scdhhs.gov/rbhsfaq .

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