CurrentCareSourcePolicy N/A

Behavioral Health Service Record Documentation Standards

Governance of required documentation standards for behavioral health services provided to Arkansas PASSE members, including record content, supervision, discharge planning, and nonmedical community supports; applies to providers rendering behavioral health services under the PASSE program in Arkansas.

Policy Summary

PayerCareSource

PolicyBehavioral Health Service Record Documentation Standards

Policy CodePolicy N/A

Change TypeOperational updates, clarifications, and removals (non-material)

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionRefer to the plan contract/Evidence of Coverage for authorization and payment decisions; documentation alone does not guarantee authorization.

SourceLink

POLICY UPDATE CHANGES

AR PASSE additions were added.

Master Treatment Plan (MTP) requirement was removed.

Non-Medical Community Supports and Services statement was added.

PCP referral is not required for behavioral health services in certain cases.

7-dayrecommended mental health practitioner follow-up after discharge

14 business daysABA treatment plan completion timeframe

2 weeksmedication supply suggested at discharge

04/28/2021→07/06/2022→10/01/2022policy issuance and revision history

21reference sources cited

Documentation-based Coverage Criteria

Documentation-based coverage criteria

Covered when documentation supports medical necessity and complies with member record standards; parity protections apply.

ALL of the following

Coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions per MHPAEA.
Administrative Policy Statements do not ensure authorization or payment; refer to the plan contract (Evidence of Coverage) for service authorization and payment determinations.
Documentation must support medical necessity for payment; medically necessary services are those proper and necessary to diagnose or treat disease, illness, or injury and meet standards of good medical practice in the local area.

Policy Summary

PayerCareSource

PolicyBehavioral Health Service Record Documentation Standards

Policy CodePolicy N/A

Change TypeOperational updates, clarifications, and removals (non-material)

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionRefer to the plan contract/Evidence of Coverage for authorization and payment decisions; documentation alone does not guarantee authorization.

SourceLink

On This Page

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Place, Modality, and Timed Service Documentation

Place/modality documentationmixed

place of service code	Documentation must reflect the location of service using the appropriate place of service code
tele-health member location	If rendered via tele-health, document the location of the member
tele-health provider location	If rendered via tele-health, document the location of the provider
tele-health modality	Document the modality of tele-health used to render the service
service code/modifier	Service code(s)/Modifier codes are appropriate for service and provider
timed service minutes	If service is based on a timed service, document total number of timed minutes and/or start and stop time with service code/type of treatment

Timed service documentation — required timing details

Timed service requirementWhen a service is based on a timed service, documentation must include the total number of timed minutes and/or the service start and stop time along with the service code/type of treatment.

Member-specific timing for groupsFor group-based services, documentation must support the member's presence for each session and, if not present for the full session, must document that member's start and stop times.

Link to billed serviceDocumentation must indicate that the services billed were the services actually provided, including timing details when applicable.

Authorization, Referral, and Provider Notices

Note

Documentation does not ensure authorization or payment

Documentation in the policy does not guarantee that a service is authorized or that payment will be made. Providers must refer to the member’s plan contract or Evidence of Coverage for final determinations about service authorization and payment responsibility.

Prior Authorization

PCP referral not required for behavioral health services

A PCP referral is not required for a member to receive behavioral health services per the policy revisions for the Arkansas PASSE program; providers should follow the revision note when determining referral requirements.

Key Definitions and Supervision Levels

Behavioral Health — definition

DefinitionBehavioral Health is an umbrella term that includes mental health, substance use disorder conditions, and developmental disabilities/delays such as autism.

ScopeApplies to behavioral health services documented under this policy and used throughout record requirements and treatment planning.

Relation to coverageBehavioral health documentation must meet the same standards for medical necessity and recordkeeping as other Medicaid-covered services.

General Supervision — definition and documentation

DefinitionGeneral Supervision: the supervisor must be available by telephone to provide assistance and direction if needed.

DocumentationSupervision documentation must include dates, start/end times, member identifiers, purpose, supervisor name/credentials/NPI when used for billing, type (general), and outcome.

Use caseApplies when billing or clinical protocols require supervisory oversight but the supervisor is not required to be immediately present.

Direct Supervision — definition and expectations

DefinitionDirect Supervision: the supervisor must be immediately available and interruptible to provide assistance and direction throughout the procedure; the supervisor does not need to be present in the room.

DocumentationWhen direct supervision is required, records must reflect the supervisor identity, availability type, and any supervisory actions taken during the procedure.

Operational noteDirect supervision requires immediate accessibility of the supervisor for interruption, distinguishing it from general supervision availability by phone.

Medical Necessity — definition and determination

Core definitionMedical Necessity: a service is medically necessary if it is proper and necessary to diagnose, treat, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction.

DeterminationThe determination of medical necessity may be made by the Medical Director or by the Medicaid Program Quality Improvement Organization (QIO).

Coverage impactCoverage may be denied if a service is not medically necessary or is generally regarded by the medical profession as experimental, inappropriate, or ineffective unless objective clinical evidence demonstrates necessity.

Archived policy — status and note

Archival statusThis policy is no longer active and was archived effective 07/31/2023.

Revision history noteLast revision recorded 07/06/2022 with AR PASSE additions and other updates; effective date previously listed as 10/01/2022.

Operational implicationArchived status means the policy is not current; other policies or CMS/State/NCCI guidance may still apply.