Rehabilitative Behavioral Health Services Changes

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 and are effective May 1, 2015, unless otherwise specified in this bulletin.

  1. Prior Authorizations

 

Prior authorization (PA) is required for Psychosocial Rehabilitative Services (PRS), Behavior Modification (BMOD) and Family Support (FS) for beneficiaries 0-21 years old who are receiving these services from private providers. A beneficiary may be referred to a private RBHS provider by the following state agencies: Continuum of Care, Department of Alcohol and Other Drug Abuse Services, Department of Disabilities and Special Needs, Department of Education, Department of Juvenile Justice, Department of Mental Health and the Department of Social Services. The state agency RBHS referral form must be completed and signed by a Licensed Practitioner of the Healing Arts (LPHA) or individual qualified to complete the Diagnostic Assessment (DA), as outlined in Section 2 of the RBHS provider manual. The private provider is responsible for submitting the referral form to the Quality Improvement Organization (QIO) for SCDHHS, currently KEPRO.

When a beneficiary self-refers or is referred to a private provider by an entity other than a state agency, the provider must submit to the QIO a DA and Child Behavior Check List (CBCL) or Early Learning Accomplishment Profile (E-LAP) for beneficiaries aged 0-5 or a DA and Adolescent Level of Care Utilization System (CALOCUS) for beneficiaries aged 6-21. The DA must be completed by a clinician licensed at the independent level as listed below  or can be co-signed by a clinician who is licensed at the independent level if the DA is completed by a  LPHA without an independent license.

 

  • Licensed Physician
  • Licensed Psychiatrist
  • Licensed Psychologists
  • Licensed Psycho-Educational Specialist
  • Licensed Advanced Practice Registered Nurse
  • Licensed Independent Social Worker-Clinical Practice
  • Licensed Physician Assistant
  • Licensed Professional Counselor
  • Licensed Marriage and Family Therapist

The CALOCUS must be completed by a clinician with a CALOCUS--SCDHHS provider certification. The QIO will review submitted documentation utilizing medical necessity criteria contained within the RBHS provider manual.

Prior authorization is required for PRS and FS for beneficiaries 22 years of age and older who are receiving these services from private providers. A beneficiary may be referred to a private RBHS provider by the following state agencies: Continuum of Care, Department of Alcohol and Other Drug Abuse Services, Department of Disabilities and Special Needs, Department of Education, Department of Juvenile Justice, Department of Mental Health and the Department of Social Services. The state agency RBHS referral form must be completed and signed by a Licensed Practitioner of the Healing Arts (LPHA) or individual qualified to complete the Diagnostic Assessment (DA), as outlined in Section 2 of the RBHS provider manual. The private provider must submit the referral form to KEPRO.

When a beneficiary self-refers or is referred to a private provider by an entity other than a state agency, the provider must submit to the QIO a DA.  The DA must be completed by a clinician licensed at the independent level as listed above  or can be co-signed by a clinician who is licensed at the independent level if the DA is completed by a Licensed Practitioner of Healing Arts (LPHA) without an independent license. The QIO will review submitted documentation utilizing medical necessity criteria 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 before March 1 have until June 1, 2015, to receive authorization for continuation of services.

All prior authorizations cover up to 90-day periods (ages 0-21) and 180-day periods (ages 22+) for each discrete service. Continued service requests are required for all beneficiaries regardless of original referral source and must be submitted to the QIO 10 business days prior to the expiration of the current authorization. Continued service requests must include the current Individualized Plan of Care and the most recent Service Plan Development note. The QIO will review submitted documentation utilizing medical necessity criteria contained within the RBHS provider manual. The QIO will process and make a service authorization(s) determination within five business days of receipt of a complete submission of all required information.

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.

Exception: State agencies directly providing RBHS are exempt from these prior authorization requirements.

  1. Staff Credentials

Effective July 1, 2015, a bachelor’s degree or above, or a certified Substance Abuse Specialist (SAS) affiliated with the Department of Alcohol and Other Drug Abuse Services (DAODAS) is required for the provision of PRS, BMOD and FS.

Exception: Providers’ staff directly serving children in foster care who are in a Therapeutic Foster Care (TFC) placement are exempt from this requirement. 

  1. Staff to Client Ratio (no exceptions)

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 exceptions)

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. These submissions may be emailed to 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.

The agency will make an adjustment reflecting the new rates retroactive to services provided 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

$6.52

U6

HO

Master's Level

$4.96

U7

HN

Bachelor's Level

$4.50

U8

TD

Registered Nurse (RN)

$5.42

U9

TE

Licensed Practical Nurse (LPN)

n/a

n/a

HM

< Bachelor’s Degree (TFC and SAS only)

$3.00

UA

 

Please contact the Provider Service Center at (888) 289-0709 for any questions regarding the fee for services policies indicated in this bulletin. For answers to commonly asked questions on these RBHS service changes, please visit scdhhs.gov/rbhsfaq.

 

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

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