CurrentAlabama MedicaidPolicy N/A

Rehabilitative Services (Chapter 47) - Medicaid

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State rules governing Medicaid-covered rehabilitative services for individuals with mental illness or substance use disorders in Alabama, including provider, eligibility, documentation, payment, and confidentiality requirements; applies to providers participating in Alabama Medicaid.

Policy Summary

PayerAlabama Medicaid

PolicyRehabilitative Services (Chapter 47) - Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 25, 2019

Last ReviewSep 11, 2019

Next Review DateN/A

Key ActionProviders must apply for and receive approval from the Alabama Department of Mental Health (DMH) to furnish Medicaid rehabilitative mental health or substance abuse services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Chapter 47Rehabilitative Services chapter identifier

3 years + currentRecord retention

Intake & assessmentZ code intake coverage

Oct 1, 2018Fee schedule baseline

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CurrentAlabama MedicaidPolicy N/A

Rehabilitative Services (Chapter 47) - Medicaid

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Know when Alabama Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerAlabama Medicaid

PolicyRehabilitative Services (Chapter 47) - Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 25, 2019

Last ReviewSep 11, 2019

Next Review DateN/A

Key ActionProviders must apply for and receive approval from the Alabama Department of Mental Health (DMH) to furnish Medicaid rehabilitative mental health or substance abuse services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Chapter 47Rehabilitative Services chapter identifier

3 years + currentRecord retention

Intake & assessmentZ code intake coverage

Oct 1, 2018Fee schedule baseline

Coverage Criteria

General coverage criteria

Covered when ALL of the following are met

Core coverage conditions: Services are covered only if they are rehabilitative services delineated in the Alabama Medicaid Provider Manual, Rehabilitative Services, Chapter 105, provided to Medicaid-eligible individuals and delivered based on medical necessity.

See Provider Manual Chapter 105 for service-specific criteria and benefit limits.

Eligibility: Financial eligibility is limited to individuals eligible for Medicaid under the Alabama State Plan.

See Rule No. 560-X-47-.02 for full eligibility requirements.

Provider requirements: Provider must meet applicable state and federal requirements and have demonstrated capacity and approval as required (including DMH approval or certification where specified) to furnish rehabilitative services.

Providers must comply with Rule No. 560-X-47-.03 and related Provider Manual requirements.

Diagnosis eligibility

Diagnosis and population-specific rules

Diagnosis requirement: Treatment eligibility requires a diagnosis of mental illness or substance abuse assigned by a licensed physician, licensed psychologist, licensed physician's assistant, certified registered nurse practitioner, licensed professional counselor, or associate licensed counselor as listed in the most current ICD-CM.

Per Rule No. 560-X-47-.02(2).

Z-code rules: Z codes are not covered for adult rehabilitative treatment services except that the intake evaluation and diagnostic assessment will be covered even if the resulting diagnosis is a Z code.

For children under 21 and adults receiving DHR protective services, the only Z code covered for reimbursement is Z65.9 (problem related to unspecified psychosocial circumstances).

The policy excludes most ICD-10 Z codes from coverage for adult rehabilitative treatment services. An exception is made for the intake evaluation and diagnostic assessment, which will be covered even if the resulting diagnosis is a Z code. For services to children under 21 and for adults receiving DHR protective services, the only Z code explicitly reimbursable is Z65.9 (problem related to unspecified psychosocial circumstances). These rules apply to treatment eligibility and must be applied when determining whether rehabilitative services meet the diagnosis requirement for coverage.

Coding and Billing

Payment basis for procedure codesmixed

Medicare Physician Fee Schedule rates	Procedure codes with an assigned Medicare rate (i.e. CPT codes) will use current published Medicare Physician Fee Schedule Rate for Alabama.
HCPCS (no Medicare rate)	Procedure codes without an assigned Medicare Rate on the Physician Fee Schedule (i.e. HCPCS) reimbursed 'By Report' (percentage of billed charges calculated from prior state fiscal year data).

Specific ICD-10 Z code allowanceICD-10Covered

Z65.9

Problem related to unspecified psychosocial circumstances — covered for children under 21 or adults receiving DHR protective services.

Provider Requirements and Actions

Prior Authorization

Obtain DMH approval to participate

Providers must submit an application to and receive approval from the Alabama Department of Mental Health (DMH) to provide mental health rehabilitative services under the Medicaid Rehabilitative Option program; substance abuse entities must be certified by DMH and must also submit an application and receive DMH approval to provide Substance Abuse Rehabilitative Services under the Medicaid Rehabilitative Option program.

Note

Limit services to those in Provider Manual Chapter 105

Only rehabilitative services delineated in the Alabama Medicaid Agency Provider Manual, Rehabilitative Services, Chapter 105 qualify for reimbursement; providers must follow the manual for complete service descriptions and benefit limitations.

Definitions

Rehabilitative services — definition

DefinitionRehabilitative services are specialized services of a medical or remedial nature delivered by uniquely qualified practitioners designed to treat or rehabilitate persons with mental illness or substance abuse diagnoses and provided on the basis of medical necessity.

Service settingsDirect services may be provided in the client's home, supervised living situations, organized community settings (community centers, health clinics, nursing homes), or any therapeutically appropriate setting except licensed hospital beds.

PurposeServices are intended to treat or rehabilitate persons with mental illness or substance abuse diagnoses.

Diagnosis and Z code eligibility

Authorized diagnosticiansDiagnosis must be assigned by a licensed physician, licensed psychologist, licensed physician's assistant, certified registered nurse practitioner, licensed professional counselor, or associate licensed counselor as listed in the current ICD-CM.

Level of Care Criteria

Outpatient/Rehabilitative services (community-based)

Provider approval and capacity: Provider must be certified/approved as required (e.g., DMH 310-board community mental health center certification or DMH approval for substance abuse entities) and demonstrate capacity to provide or arrange access to the required service array including inpatient referral, substance abuse services, counseling, crisis intervention, consultation/education, case management, and assessments.

Providers must meet the provider-type criteria and both additional requirements (4) and (5) in Rule No. 560-X-47-.03.

Service scope: Only rehabilitative services delineated in the Alabama Medicaid Provider Manual, Rehabilitative Services, Chapter 105 qualify for reimbursement.

A complete description of each covered service and benefit limitations is in Provider Manual Chapter 105 (Rule No. 560-X-47-.06).

Access and confidentiality: Provider must demonstrate capacity to provide services off-site in a manner that assures the recipient's right to privacy and confidentiality and must demonstrate reasonable access to services (service locations, hours, coordination with community resources).

Treatment Modalities

Community rehabilitative behavioral health services

Service modalities: Array includes individual, group, and family counseling; crisis intervention; consultation and education; case management; assessment and evaluation; substance abuse intensive outpatient and residential services; referral to inpatient services; and other rehabilitative services as defined in Provider Manual Chapter 105.

Medicaid does not cover all listed services but the provider must demonstrate capacity to provide them (Rule No. 560-X-47-.03 and Rule No. 560-X-47-.06).

Benefit Limits and Visit Rules

Benefit limitations and covered services (see Provider Manual Chapter 105)

Scope of covered servicesOnly rehabilitative services delineated in the Alabama Medicaid Agency Provider Manual, Rehabilitative Services, Chapter 105 qualify for reimbursement under this program.

Benefit descriptions and limitsA complete description of each covered service and its benefit limitations is contained in the Medicaid Provider Manual, Rehabilitative Services, Chapter 105; quarterly updates available from the Medicaid website.

Supervisory requirementsServices must be provided in a manner that meets supervisory requirements of the respective certifying or licensing authority or as authorized by state law.

Background

Rehabilitative services are defined as specialized medical or remedial services provided by qualified practitioners to treat or rehabilitate individuals with mental illness or substance use disorders. Coverage is limited to Medicaid-eligible individuals with a qualifying diagnosis assigned by an authorized clinician and services must be delivered based on medical necessity. Direct services may be provided in community or home settings that are therapeutically appropriate and respect privacy, and providers must meet applicable certification and compliance requirements to participate in Alabama Medicaid.

Policy Summary

PayerAlabama Medicaid

PolicyRehabilitative Services (Chapter 47) - Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 25, 2019

Last ReviewSep 11, 2019

Next Review DateN/A

Key ActionProviders must apply for and receive approval from the Alabama Department of Mental Health (DMH) to furnish Medicaid rehabilitative mental health or substance abuse services.

SourceLink

On This Page

Documentation Required

Include minimum documentation elements in each client record entry

Each client's record entry for every session, service, or activity submitted for Medicaid reimbursement must include: identification of the specific service rendered; the date and amount of time services were rendered; the signature of the staff person who rendered the services; identification of the setting in which services were rendered; and a written assessment of the client's progress or lack thereof related to identified clinical issues. The author of each entry must be identified and must authenticate the entry consistent with Chapter 1 signature requirements.

Identification of specific services rendered
Date and amount of time services were rendered
Signature of the staff person who rendered services
Identification of the setting for services
Written assessment of client progress or lack thereof
Author identified and entry authenticated per Chapter 1

Denial Risk

Maintain documentation to avoid recoupment

When clinical records are audited, Medicaid will apply the minimum documentation standards from Rule 560-X-47-.05(2); documentation failing to meet those standards will result in recoupment of payments.

Documentation Required

Grant audit access and retain records for 3 years + current

Providers must make available at no charge all information regarding claims submitted and paid and must permit access to all records and facilities for claims audit, program monitoring, and utilization review by authorized federal and state representatives. Records shall be retained for a period of three years plus the current year and/or until completion of any audit. Certain services do not require recipient signatures (see list in Rule 560-X-47-.11(2)).

Provide records and facility access at no charge for audits and monitoring
Retain records for three years plus the current year or until audit completion
Recipient signature exceptions include Treatment Plan Review, ACT, PACT, Behavioral Health Placement Assessment, crisis intervention, psychoeducational services, Mental Health Care Coordination, and non-face-to-face telephone services

Denial Risk

Risk of recoupment and audit findings for inadequate records

Failure to maintain complete and accurate rehabilitative and fiscal records for the retention period that fully disclose the extent of services may lead to recoupment of payments and adverse audit findings.

Z code rule — adultsZ codes are not covered for adult rehabilitative treatment services; however, intake evaluation and diagnostic assessment are covered even if the resulting diagnosis is a Z code.

Z65.9 allowanceFor children under 21 or adults receiving DHR protective services, the only Z code covered for reimbursement is Z65.9 (problem related to unspecified psychosocial circumstances).

See Rule No. 560-X-47-.03(4).

Quality and coordination: Provider must ensure recipients receive quality, coordinated services with reasonable access to an adequate array of services delivered flexibly to meet needs.

Failure to maintain quality, access, or documentation may result in recoupment or loss of reimbursement (see Rule No. 560-X-47-.03(5) and documentation requirements).