Documentation requirements and conditions of coverage for behavioral health services under Arkansas PASSE.
Each member must have a legible medical record that includes the member's name, date of service, and page numbering; documentation must include diagnosis and the signature, date, and credentials of the practitioner, and must indicate that the services billed were the services provided.
Timed and group services must document service-specific details: for timed services, the total number of timed minutes and/or start and stop times and associated service codes/type of treatment; for group services, documentation that the member was present (and start/stop times if not present the full session), names/credentials/relationships of other professionals present, and the number of participants.
Documentation must reflect appropriate coding and place of service: service code/modifier must be appropriate for service and provider, and the record must document the location of service using the appropriate place of service code; for tele‑health, document the location of the member, the location of the provider, and the modality used.
Clinical documentation must demonstrate medical necessity and specific needs/interventions/progress toward treatment plan goals; duplication of notes is not acceptable.
Documentation change and correction standards: EMR amendments or delayed entries must identify the amendment and retain a reliable method to identify original and modified content and who modified it; paper record changes must be clearly visible, not use white‑out, and be crossed out with a single line, labeled as error, initialed, and dated.
Diagnostic and assessment requirements: records must include allergies, relevant standardized assessment tools and results when pertinent, a psychiatric assessment and mental status exam (including judgment/insight, orientation, memory, mood/affect, vital signs, behavior, and estimated intellectual functioning), and a summary/diagnosis/plan. A Mental Health Evaluation/Diagnosis should be completed by an appropriately licensed Arkansas mental health professional; a Psychiatric Diagnostic Assessment by a physician/APRN is not required unless deemed medically necessary, and a PDA performed within 6 months need not be repeated absent change in functioning.
Treatment plan requirements: plans must document type, amount, frequency, and duration of services; provider; mutually agreed, age‑appropriate, quantifiable goals with target dates and measurable criteria for continued stay; estimated length of stay/course of treatment; criteria for discharge; and evidence the plan was reviewed with the member (and as appropriate family/guardian).
Applied Behavior Analysis (ABA) specific requirements: ABA treatment plans must connect behavioral assessment results to member‑specific goals with baseline data, measurement, and mastery criteria; be based on the member's daily activities; should be signed by the Mental Health Professional directing treatment (signature by a licensed physician not required); should be completed within 14 business days of the Mental Health Evaluation/Diagnosis; and should be periodically reviewed when significant change occurs or at least every 6 months.
Progress note expectations: inpatient and outpatient psychiatric progress notes must document relevant clinical material including summary of change/symptoms since prior note, response to medications and rationale for medication changes, and mental status exam elements; progress notes are best practice to be written within 24 hours and signed within 14 days.
Discharge planning and follow‑up: discharge planning evaluation must assess treatment regimen and rehabilitation needs, connections to outpatient/community resources, scheduled follow‑up within 7 calendar days of discharge (and coordinate transportation), medication reconciliation and provision as appropriate, availability of services, readmission risk, social determinants of health, and must provide necessary information/referrals to follow‑up providers.
Supervision documentation: supervision notes must include dates, start/end times, member identifiers, purpose/outcome, supervisor name/credentials/NPI if applicable for billing, type of supervision, scope validation, and signatures; ABA supervision must include additional elements such as review of data, progress, monitoring tools, and collaboration with treatment team.
Nonmedical Community Supports and Services (NCSS) as a condition of coverage: NCSS are available under federal authorities and Arkansas Act 775 for PASSE members to prevent or delay institutionalization and support community living; NCSS must be rooted in member needs identified by the Independent Assessment and included in the Person‑Centered Service Plan (PCSP), and should be reviewed and updated through care coordination and the PCSP process.
Integrity and legal considerations: deliberate falsification of medical records is prohibited and may be a felony (examples include creating new records on request, back‑dating, post‑dating, overwriting entries, or unauthorized additions); legally amended corrections made prior to claims submission will be considered, but corrections after payment determination may not alter payment; appeals for denials based on incomplete records may succeed if original components omitted on initial review are supplied.